The urgency of the problem is difficult to overstate. Firearm injuries have surpassed motor vehicle crashes as the leading cause of death among U.S. children, and the Surgeon General declared firearm violence a public health crisis in 2024. Yet despite these alarming trends, physicians rarely intervene through patient counseling or policy advocacy, likely because few receive any formal training during their education. The OHSU team, led by Dr. Katherine A. Iossi, recognized that if physicians are expected to play a role in preventing firearm injuries, medical schools must equip students with the tools to do so before they enter clinical practice.

The session, developed in collaboration with public health professionals, was integrated into the existing second-year medical student curriculum at OHSU. It comprised three carefully sequenced components: didactic instruction outlining firearm injury epidemiology and evidence-based clinical and policy interventions, facilitated small-group discussions, and role-playing exercises to practice clinical and policy advocacy skills. The design drew on established curriculum development frameworks and incorporated the BulletPoints Project’s 3A’s Framework for firearm safety counseling, along with the structured advocacy pitch model for policy engagement.

The didactic portion grounded students in the epidemiology of firearm injuries, covering the spectrum of harm from suicide and homicide to accidental injury, and presenting evidence-based interventions such as lethal means safety counseling and secure firearm storage. Students then moved into facilitated small-group discussions, where they explored the ethical dimensions of firearm injury prevention and examined the concept of the physician’s “lane,” a reference to the ongoing debate about whether firearm safety falls within the scope of medical practice. The discussions were structured to create psychological safety, allowing students to voice uncertainty and engage with the topic without fear of judgment.

The role-playing component represented the most innovative element of the session. Students practiced clinical counseling scenarios, such as discussing secure firearm storage with a patient at risk for suicide, and rehearsed policy advocacy pitches aimed at translating clinical evidence into legislative action. This experiential approach reflects a growing body of evidence that communication skills are best acquired through deliberate practice rather than passive instruction, and it mirrors the simulation-based methods used to teach other sensitive clinical encounters.

To evaluate the program, the researchers administered a retrospective pre-post survey to participating students, achieving a response rate of 71.4 percent with 105 respondents. The results revealed statistically significant increases in all study variables between the pre- and post-periods, with p-values below 0.001. Students reported meaningful gains in perceived knowledge, confidence, and intention to engage in firearm injury prevention efforts. Approximately half of respondents, 48.6 percent, reported at least some experience with firearms, including having a family or cultural background involving firearms, highlighting the diversity of perspectives students bring to the topic.

Respondents viewed the firearm injury prevention education as timely, educationally valuable, and important to their future practice. The findings suggest that even a brief, well-structured session can shift medical students’ attitudes and self-efficacy in a domain where clinical engagement has historically been low. The researchers note that self-efficacy plays a mediating role in professional identity formation, meaning that early exposure to firearm injury prevention could influence how students see themselves as physicians throughout their careers.

The program’s significance extends beyond a single institution. Prior educational interventions in this domain have been limited and fragmented, ranging from web-based curricula to case-based training for residents, but few have combined clinical counseling with policy advocacy in a single session for preclinical medical students. The OHSU team’s approach, which explicitly frames firearm injury prevention as both a clinical and policy responsibility, addresses consensus-driven priorities for firearm injury education among medical professionals identified by national summits on the topic.

The researchers acknowledge limitations inherent in their evaluation design, including the retrospective self-report method and the single-institution setting. Response bias remains a possibility, and the long-term retention of knowledge and skills was not assessed. Nevertheless, the study provides a replicable template for other medical schools seeking to integrate firearm injury prevention into their curricula, and the de-identified data is available from the corresponding author upon request to facilitate further research.

As the firearm injury epidemic continues to claim tens of thousands of lives annually, the OHSU session offers a concrete example of how medical education can respond. By teaching students to counsel patients on firearm safety and to advocate for evidence-based policies, the program challenges the notion that physicians must remain silent on this issue. The title of the session, “It’s in Our Lane,” captures the researchers’ central message: firearm injury prevention is not a political distraction but a clinical and professional obligation that belongs squarely within the practice of medicine.

Subject of Research: A medical education program training students in firearm injury prevention clinical counseling and policy advocacy skills

Article Title: It’s in Our Lane: A Firearm Injury Prevention Clinical and Policy Advocacy Skill Development Session for Medical Students

Article References: Iossi, K. A., Kane, R. M., Teichman, R., Manley, K., Martinson, T., Carlson, K. F., Carney, P. A., & Burnett, J. R. (2026). It’s in Our Lane: A Firearm Injury Prevention Clinical and Policy Advocacy Skill Development Session for Medical Students. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10716-9

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10716-9

Keywords: firearm injury prevention, medical education, physician advocacy, public health, curriculum development, health policy, communication skills, medical students, Lane, Firearm, Injury, Prevention

Medicare Administrative Contractors, or MACs, sit at the operational heart of the Medicare fee-for-service system. Under Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, they became the sole contractors responsible for processing Medicare Part A and B claims, along with claims for durable medical equipment. Their portfolio is vast: they issue payments, enroll providers into the program, audit cost reports, handle redetermination requests, review medical records, respond to provider inquiries, and educate clinicians on billing requirements. The scale is staggering. In 2023 alone, MACs processed more than 1.2 billion Medicare claims, generating roughly 430 billion dollars in payments, out of approximately ten billion total claims submitted across all payers in the United States that year.

The growing importance of this infrastructure tracks with the expansion of Medicare itself. The program, which serves adults aged 65 and older, people with disabilities, and patients with conditions such as end-stage renal disease, is projected to grow from 61.2 million beneficiaries in 2020 to about 80 million by 2030. As that population expands, so does the use of dermatologic services, making the mechanics of Medicare reimbursement an increasingly consequential subject for clinical practice. Yet most dermatologists receive little formal education in how the system actually works, a gap the review’s authors describe as a serious blind spot in the specialty.

The most consequential power MACs hold is the ability to write regional coverage policy. Medicare’s National Coverage Determinations, issued centrally by CMS, provide standardized guidelines meant to ensure uniform care across the country, but they cover only a fraction of medical services. Where the national guidance ends, MACs fill the void with Local Coverage Determinations, or LCDs: jurisdiction-specific policies that define which services are reimbursed, specify eligibility criteria, and establish the parameters within which clinicians are expected to make decisions. Because these policies are drafted at each contractor’s discretion, significant regional variations arise, meaning the same procedure may be covered readily in one state and subjected to strict documentation requirements in another.

The structure of the system is a legacy of contract geography rather than coherent health planning. Twelve Part A/B jurisdictions and four durable medical equipment jurisdictions are currently divided among seven contractors, many of which group together states with little regional or demographic similarity. Noridian Healthcare Solutions covers much of the western United States, National Government Services handles the Northeast and Midwest, WPS Health Solutions and CGS Administrators split parts of the Midwest and Ohio Valley, Novitas Solutions serves the mid-Atlantic and South, Palmetto GBA the Southeast, and First Coast Service Options covers Florida and the U.S. territories. Although the jurisdictions have remained relatively stable, periodic contract rebidding can shift oversight from one company to another, potentially reshuffling policy priorities over time.

Making sense of LCDs requires understanding their lifecycle, which is lengthy and, unusually for healthcare bureaucracy, partially open to public participation. The process begins with informal meetings between the MAC and interested parties. Healthcare professionals, Medicare beneficiaries, medical vendors, manufacturers, and advocacy groups operating within a contractor’s jurisdiction can all submit requests for new coverage policies, provided they identify the applicable benefit category, supply a supporting rationale, and back their case with peer-reviewed evidence on clinical relevance and health outcomes. There is no fixed deadline for the MAC’s response, so months can pass before an official decision to proceed.

If the contractor moves forward, it conducts a comprehensive review of the medical literature, including clinical trials, systematic reviews, and existing guidelines, then drafts a proposed LCD and posts it on the Medicare Coverage Database for public comment. Draft policies are identified by a leading letter D before the standard identifier, which begins with L followed by a five-digit code. The comment period lasts at least 45 calendar days, during which the MAC must host open meetings, announced in advance on its website, where stakeholders can comment and present evidence. In some cases, a Contractor Advisory Committee, an official panel of healthcare professionals, beneficiary representatives, and medical organizations, reviews the quality of the evidence to ensure an unbiased assessment. The entire journey from initial request to implemented policy can take from several months to years, and even then, LCDs are periodically revisited as new clinical evidence, stakeholder requests, or new national determinations emerge.

The review highlights Mohs micrographic surgery, the tissue-sparing gold standard for high-risk non-melanoma skin cancers, as a case study in how far regional policies can diverge. Utilization of the technique in Medicare populations rose 25 percent between 2009 and 2013, yet the criteria for reimbursement differ sharply by jurisdiction. Some contractors, including WPS and Noridian, have written LCDs that closely mirror the specialty’s Appropriate Use Criteria, breaking down eligibility by tumor size measured in centimeters, histology, anatomic location, and patient comorbidities, leaving little room for clinical judgment. Others, such as First Coast Service Options in LCD L33689, apply the same criteria more flexibly, emphasizing documented clinical reasoning for why Mohs surgery is preferable to standard excision. Palmetto GBA’s policy takes a similarly documentation-driven approach without explicitly citing the national criteria at all.

Those differences are not academic. A patient with a particular skin cancer on a particular part of the body may sail through coverage in one jurisdiction and face claim denials or audits in another, simply because the neighboring contractor wrote a stricter policy. Denials and audits translate into treatment delays, heavier administrative workloads, and physician burnout, ultimately compromising the quality and timeliness of care. The authors caution that less common or more specialized dermatologic services may face even greater inconsistencies than Mohs surgery, and they acknowledge that their review, being descriptive and policy-focused, cannot establish causal links between coverage rules and clinical outcomes.

The central prescription of the review is engagement. Dermatologists can identify which MAC governs their region, monitor existing and draft LCDs through the Medicare Coverage Database, submit evidence-based comments during public comment periods, attend and present at contractor-hosted open meetings, and use the formal reconsideration process to request revisions to active policies supported by new clinical evidence. Professional societies such as the American Academy of Dermatology offer advocacy training and policy education, while state societies and Contractor Advisory Committee panels provide additional channels. In a system where private insurers often make coverage decisions with minimal transparency and little opportunity for provider input, the MAC framework, for all its complexity, is at least navigable. The authors’ message is blunt: physicians who understand and participate in this process can help shape the rules, while those who do not remain subject to them.

Subject of Research: The role of Medicare Administrative Contractors and Local Coverage Determinations in regional dermatology reimbursement policy in the United States

Article Title: The Role of Medicare Administrative Contractors and Local Coverage Determinations in Dermatology Policy

Article References: Sandhu, A., Mehrmal, S., & Tolkachjov, S. N. (2026). The Role of Medicare Administrative Contractors and Local Coverage Determinations in Dermatology Policy. Archives of Dermatological Research, 318(1), 421. https://doi.org/10.1007/s00403-026-04698-1

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04698-1

Keywords: Medicare, Medicare Administrative Contractors, Local Coverage Determinations, dermatology, health policy, reimbursement, Mohs micrographic surgery, Centers for Medicare and Medicaid Services, health insurance, coverage policy, physician advocacy, skin cancer

The premise behind the conference rests on a tension that has long troubled medical educators. The Accreditation Council for Graduate Medical Education formally recognizes advocacy as a core competency for residents, meaning that programs are expected to produce physicians who can speak up for patients not only at the bedside but in the arenas where health-determining decisions are actually made. Yet national surveys of residency program directors have repeatedly shown that dedicated advocacy curricula remain scarce, fragmented, or optional. A systematic review of advocacy curricula in graduate medical education found that while interest is widespread, structured, experiential opportunities are the exception rather than the rule. Residents frequently graduate having never drafted a policy brief, never testified, and never met a legislator, despite being expected to understand how legislation shapes everything from insurance coverage to housing policy that affects their patients.

The organizers of the California conference, led by Natalie Colaneri of the University of California San Diego along with colleagues from UC San Francisco, UC Davis, and Stanford School of Medicine, set out to close that gap with a deliberately practical design. Rather than confining the training to lectures about the legislative process, they built a two-day experience that culminated in real meetings with state legislators. The first day was devoted to skill-building: didactic sessions on how the California legislature works, workshops on crafting and delivering an effective advocacy message, mock legislative meetings in which residents could rehearse their pitches and receive feedback, and a career panel featuring physicians who have made advocacy a central part of their professional lives. The second day moved the residents out of the classroom and into the Capitol itself, where they met with legislators and their staff to discuss policy issues relevant to the health of their communities.

What distinguishes this program from many earlier advocacy curricula is its community-engaged architecture. The conference was developed in partnership with the California Pan-Ethnic Health Network, a Sacramento-based organization focused on health equity for communities of color, and the End the Epidemics Coalition, a statewide campaign addressing the intertwined epidemics of HIV, viral hepatitis, sexually transmitted infections, and overdose. The GLIDE Foundation in San Francisco, a longtime provider of services to San Francisco’s most marginalized residents, also supported the effort. Community partners helped identify policy priorities and grounded the training in the lived realities of the populations residents serve, rather than in the abstract language of policy white papers. This co-creation approach reflects a growing body of educational theory suggesting that curricula designed jointly with stakeholders, including community members, produce learning that is more relevant, more durable, and more likely to change behavior.

The multi-institutional dimension was equally deliberate. Residents came from internal medicine programs across the University of California system and Stanford, meaning that the conference pooled trainees who would otherwise never learn together. This design carries practical advantages beyond economies of scale. Legislative advocacy is inherently relational, and building a network of physician-advocates across institutions creates a durable cohort that can support one another’s policy work long after residency ends. It also signals to residents that advocacy is not the idiosyncratic passion of a single mentor at their home program but a shared professional expectation across major California training centers. Funding came from a patchwork of institutional sources, including endowed teaching chairs, community grants, and a workforce training grant from the California Department of Health Care Access and Information, illustrating both the feasibility and the fragility of this kind of collaboration.

The evaluation, though modest in scale, delivered striking results. Sixteen of the forty-five residents completed a post-conference survey, and among those respondents the findings were unanimous. One hundred percent reported gaining relevant skills to participate in advocacy, and one hundred percent reported an increased likelihood that they would participate in advocacy in the future. A majority rated every individual session as having a major or moderate impact on their advocacy training, and every single respondent assigned that level of impact to the meetings with legislators. In medical education research, where survey interventions often produce incremental gains on Likert scales, a uniformly positive response is notable, and the organizers point to the experiential format, particularly the real legislative meetings, as the likely driver of that enthusiasm.

The findings align with a broader evidence base on advocacy training. Prior studies of single-day legislative advocacy experiences, including work with physicians-in-training published in BMC Medical Education, have shown that even brief exposure to the legislative process can improve self-reported competencies and attitudes. A three-tiered pediatric curriculum in New York demonstrated that residents can be taught advocacy at the individual, community, and legislative levels through a longitudinal design. What the California conference adds is a demonstration that such training can be delivered across multiple institutions simultaneously, with community organizations as genuine partners rather than token collaborators, and that the model can be mounted in a single academic year by a volunteer organizing team. The authors frame the conference as a template that other states and specialties could adapt, potentially multiplying its reach well beyond the forty-five residents who attended.

The study’s authors are candid about the obstacles. Funding was a persistent challenge, assembled from multiple grants rather than a stable institutional commitment. Time constraints loomed large, since residents operate under rigid clinical schedules and duty-hour limits, and pulling forty-five trainees out of their programs for two days required significant coordination. Identifying policy priorities that resonated across diverse institutions and communities demanded extensive negotiation with community partners. The low survey response rate of sixteen out of forty-five also limits the certainty of the conclusions, a limitation the authors acknowledge; the unanimous enthusiasm among respondents may partly reflect self-selection by residents who were already most engaged. Still, the program was reviewed and exempted by institutional review boards at all participating universities, and the organizers published their materials so that others can replicate the design.

The stakes of this kind of training extend well beyond residency education. Physicians occupy a distinctive position of public trust, and studies dating back more than a decade have documented that the public regards physicians as credible voices on health policy. Yet surveys of practicing physicians have consistently found that most engage in little or no political activity, citing lack of time, training, and confidence. If advocacy is genuinely a core competency, then the pipeline problem begins in training, and interventions like the California conference represent an attempt to intervene at the moment when professional identity is still forming. The residents who met with legislators in Sacramento in May 2025 may or may not become career policy advocates, but the evaluation suggests they now see advocacy as something they are equipped to do, not merely something they are told matters.

For the broader medical education community, the California experiment offers a practical answer to a question that has lingered since advocacy entered the competency framework: not whether physicians should be trained to advocate, but how. The answer emerging from Sacramento is experiential, communal, and collaborative, pairing classroom preparation with real-world practice and pairing academic institutions with the community organizations that understand health inequities most intimately. As the authors conclude, the conference addresses a genuine gap in resident education and offers a model for future community-engaged, multi-institutional collaborations. Whether that model spreads will depend on funding, institutional will, and the willingness of residency programs to treat the statehouse as an extension of the teaching hospital. The forty-five residents who made the trip suggest there is no shortage of demand among the trainees themselves.

Subject of Research: A legislative advocacy training conference for internal medicine residents developed with community coalitions in California

Article Title: Establishing a Multi-Institutional, Community-Engaged California State Legislative Advocacy Conference for Internal Medicine Residents

Article References: Colaneri, N., Griffiths, E. P., Teasdale, S., Jain, S., Charat, S., Santiago, C., Yamamoto, K., Binder, E., & Shankar, M. (2026). Establishing a Multi-Institutional, Community-Engaged California State Legislative Advocacy Conference for Internal Medicine Residents. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10717-8

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10717-8

Keywords: physician advocacy, legislative advocacy, medical education, internal medicine residency, health equity, graduate medical education, community engagement, health policy, California legislature, ACGME core competencies, curriculum design, advocacy training