The trial compared two teaching strategies delivered during the same 12-week general practice rotation at First Affiliated Hospital of Huzhou Normal University and the First People’s Hospital of Huzhou. Each group received 24 instructional hours covering six clinical cases: hypertension, community-acquired pneumonia, type 2 diabetes, heart failure, chronic obstructive pulmonary disease and acute kidney injury. The flipped classroom combined with team-based learning, abbreviated FC-TBL, moved foundational instruction into short prerecorded videos and quizzes completed before class. Contact time was then devoted to individual and team readiness tests, team-based application of clinical cases, structured feedback and reflection. The comparison group received instructor-centered lectures on the same content, followed by a clinical demonstration, but no student practice, team activities, readiness tests, application exercise, structured feedback or reflection log.

Residents assigned to FC-TBL improved by 6.79 points on the clinical reasoning rubric from baseline to the immediate post-test, compared with an increase of 3.17 points in the lecture group. The authors calculated an effect size of 2.59 for the difference in improvement and reported post-hoc power above 0.99. The trial had been powered before enrollment for 28 participants per group, based on an assumed moderate between-group effect and a target of 80% power at a two-sided significance level of 0.05. All 56 randomized residents completed the intervention and follow-up, and baseline characteristics—including age, sex, undergraduate education, National Medical Licensing Examination scores and clinical reasoning—did not differ significantly between the groups. The absence of a baseline imbalance and the retention of a group difference at four weeks support the observed association, although the trial did not separate the effects of the flipped classroom and team-based learning components.

The active-learning group also received higher ratings on workplace performance assessments conducted immediately after the intervention. Its mean Mini-CEX score exceeded that of the lecture group in all seven domains: medical interviewing, physical examination, clinical reasoning, organization and efficiency, doctor-patient communication, humanistic care and overall clinical performance. For example, clinical reasoning averaged 8.04 versus 6.07, while overall clinical performance averaged 7.86 versus 6.07 on nine-point scales. The highest Mini-CEX score for the FC-TBL group was 8.04, whereas the highest reported mean for the lecture group was 6.32. Similarly, residents trained with FC-TBL scored higher in every measured Direct Observation of Procedural Skills domain, covering indications and contraindications, informed consent, preparation, technical execution, communication, professionalism and overall procedural proficiency. Overall procedural proficiency averaged 7.86 in the FC-TBL group and 6.04 in the lecture group, while technical execution averaged 7.71 and 5.89, respectively. All reported differences across these Mini-CEX and DOPS measures were significant at p-values below 0.001.

Questionnaires showed a parallel shift in residents’ reported learning experience. Mean teamwork scores were 86.42 in the FC-TBL group and 72.15 in the lecture group immediately after training, while self-directed learning scores were 85.73 and 70.88 and learning-engagement scores were 87.15 and 71.43. These advantages persisted at the four-week assessment: teamwork averaged 84.97 versus 71.06, self-directed learning 84.21 versus 70.14, and learning engagement 85.68 versus 70.92, with all differences reported at p-values below 0.001. Teaching satisfaction was also higher across all four measured dimensions: residents gave the active model mean scores of 88.57 for teaching-mode design, 87.86 for stimulation of learning interest, 86.79 for improvement of the learning process and 89.29 for overall satisfaction, compared with 72.14, 70.54, 71.07 and 73.57 in the lecture group. These results describe the response to the combined instructional strategy; they do not identify which component produced the difference.

The approach carried an immediate cost in perceived pressure. FC-TBL residents reported higher stress immediately after the intervention, averaging 62.34 on a 100-point scale, compared with 54.17 in the lecture group, a difference reported at p < 0.001. By the four-week follow-up, the difference had disappeared: mean stress was 51.28 and 50.96, respectively, with p = 0.892. The trial therefore measured a temporary increase in reported stress associated with the new model rather than evidence of persistent psychological harm. The authors considered orientation for active-learning demands a possible implementation consideration, but that suggestion was an implication of the study rather than an intervention that was separately tested.

Within FC-TBL sessions, the investigators also compared an individual readiness assurance test, or iRAT, with a subsequent team version, the tRAT. Residents first completed ten multiple-choice questions alone, then worked in teams of five or six to discuss the same questions, reach consensus and submit answers with immediate feedback. The individual test averaged 7.82 correct answers, while the team test averaged 9.21, a mean difference of 1.39 with p < 0.001. This within-group comparison showed higher test performance after team discussion, but it did not isolate team discussion from the immediate feedback provided by the scratch-card system. Nor did it determine which part of the combined FC-TBL program was chiefly responsible for the larger improvements observed against lecture-based learning. The result is therefore compatible with the authors’ proposed explanation that discussion and peer explanation can surface misunderstandings, but it is not a component-level test of that mechanism.

The practical distinction lay in how the groups used the same limited contact time. A representative hypertension session began with a 12-minute video and a five-question online quiz completed three to four days before class, followed by an in-class individual readiness test. Teams then analyzed a 65-year-old patient with uncontrolled hypertension, poor medication adherence, type 2 diabetes, leg edema, low potassium and reduced estimated glomerular filtration rate. Their task was to identify key problems, generate a differential diagnosis, revise treatment, plan patient education and arrange follow-up. Team presentations and an instructor-led debriefing then compared their responses with evidence-based guidelines before residents completed a brief structured reflection log. In contrast, the lecture group received the same case content and total contact time through a 90-minute instructor lecture and a 30-minute clinical demonstration, with questions permitted at the end. The comparison therefore tested a complete change in instructional strategy across the 12-week course, not the addition of occasional team activities to a few otherwise unchanged lectures.

Despite the size of the reported differences, several limitations constrain how far the findings can be generalized. The trial involved only 56 residents at one hospital, all of whom completed it, so the results may not transfer to other institutions, larger cohorts or different residency structures. Residents and instructors could not be blinded to their teaching method, although independent assessors were blinded for performance evaluations, leaving some potential for behavioral bias. Follow-up lasted only four weeks, which cannot establish durable changes in clinical skills, independent practice or patient outcomes. The Lasater Clinical Judgment Rubric depends partly on observer ratings and may be more subjective than standardized patient encounters or objective structured examinations, even though two trained blinded assessors scored performances independently. The teaching-satisfaction questionnaire was adapted for this context and may require further psychometric validation. Larger multicenter trials with longer follow-up, comparisons that separate the two instructional components and cost analyses would be needed to establish the model’s broader effectiveness and mechanisms.

Subject of Research: Randomized trial of flipped classroom and team-based learning for general practice residency training

Article Title: Effectiveness of a flipped classroom combined with team-based learning in standardized training of general practice residents: a randomized controlled trial

Article References: Xiao, M., Wang, Y., Gao, Y., Shi, S., & Qian, C. (2026). Effectiveness of a flipped classroom combined with team-based learning in standardized training of general practice residents: a randomized controlled trial. Frontiers in Medicine, 13, Article 1931590. https://doi.org/10.3389/fmed.2026.1931590

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1931590

Keywords: medical education, clinical reasoning, flipped classroom, team-based learning, residency training, randomized controlled trial, general practice, active learning, workplace assessment, Effectiveness, flipped, classroom

The findings show that residents’ and supervisors’ perceptions of competence did not align uniformly, but the study did not follow the same individuals over time and therefore cannot establish that either group changed as training progressed. Researchers enrolled 156 internal medicine resident physicians who were completing cardiovascular medicine rotations at the hospital between January 2024 and November 2025. They grouped participants into three cohorts—PGY1, PGY2 and PGY3—and selected 22 trained supervisor physicians to serve as evaluators.

Each resident and supervisor provided scores through a 15-item entrustable professional activity questionnaire. The questionnaire was designed to capture perceived competence across professional activities, with residents assessing themselves and trained supervisors assessing the same residents. The residents’ self-assessment results were more limited: self-rated performance differed significantly among cohorts only for basic clinical tasks, while ratings for high-complexity competencies did not differ significantly between PGY2 and PGY3 residents.

Radar-chart comparisons showed that PGY1 residents’ self-assessment scores were significantly higher than their supervisor scores for every EPA examined. That discrepancy narrowed in PGY2. Among PGY3 residents, by contrast, supervisor scores were significantly higher than self-assessment scores for multiple EPAs.

These were comparisons between separate cohorts, not measurements of longitudinal change within individual residents. Exploratory analyses also examined whether self-assessment scores differed by gender within each training cohort. PGY1 and PGY2 residents did not show significant self-assessment differences between male and female participants.

In the PGY3 cohort, however, male residents gave significantly higher self-ratings than female residents for specific diagnostic and technical EPAs. The study did not establish the cause of these subgroup differences, and the authors described the gender analyses as exploratory. The findings therefore identify a difference within one senior cohort rather than a general pattern across the entire sample or a demonstrated gender effect in cardiovascular medicine training.

The results support further evaluation of integrated self- and supervisor-rated EPA assessment as a way to distinguish residents at different training stages and inform individualized feedback. These limitations follow directly from the single-center, cross-sectional design: differences among PGY cohorts cannot be interpreted as improvements over time, and the results may not generalize beyond the hospital studied. The investigators concluded that longitudinal, multicenter studies are needed to determine whether the EPA-based tool can reliably track competence, respond to training-related changes and provide meaningful educational value.

Until then, the observed disparities are best understood as differences between resident and supervisor perceptions in a single Chinese hospital cohort, not as evidence of developmental trajectories or training outcomes.

Subject of Research: Self- and supervisor-rated EPA assessments of cardiovascular medicine residents in China

Article Title: Entrustable professional activities for cardiovascular medicine residents in China: a cross-sectional study

Article References: Peng, M., Chen, L., Ye, Q., Hu, Q., Shi, R., Bai, Y., Liu, S., & Zeng, W.-J. (2026). Entrustable professional activities for cardiovascular medicine residents in China: a cross-sectional study. BMC Medical Education. https://doi.org/10.1186/s12909-026-10353-0

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10353-0

Keywords: cardiology residents, entrustable professional activities, competency assessment, self-assessment, supervisor ratings, medical education, residency training, gender differences, China, Entrustable, professional, activities

The research, led by Dr. Georgia M. Vasilakis of the UPMC Heart & Vascular Institute alongside Dr. Kaitlyn E. McSurdy, Dr. Kathryn Berlacher, and Dr. Natalie Stokes, is a cross-sectional survey study — a snapshot in time of attitudes and behaviors across a single academic medical community. Cross-sectional designs like this one capture prevalence and perception rather than causation, but they are precisely the instrument needed when a technology has spread faster than the literature describing it. Graduate medical education, the period when medical school graduates train as residents and fellows under faculty supervision, is an especially revealing setting, because it pairs the least experienced clinicians with the most experienced ones and asks how both groups respond to the same unfamiliar technology.

The urgency of the question is hard to overstate. Generative AI systems — large language models that can draft prose, summarize evidence, answer clinical questions, and simulate patient encounters — have penetrated professional life at a pace with few precedents in medicine. Surveys of physicians conducted by the American Medical Association in 2026, cited in the study’s bibliography, document rapidly shifting sentiment toward augmented intelligence in clinical practice. Yet formal guidance has lagged well behind adoption. A 2025 report from the Association of American Medical Colleges found that artificial intelligence curricula remain unevenly implemented across U.S. and Canadian medical schools, meaning many trainees arrive in residency having never received structured instruction in what these tools can do, when they fail, or how their outputs should be verified.

That gap between use and instruction is the study’s central concern. The title’s nautical metaphor — sailing by the stars — is deliberate. Generative AI offers trainees a navigational aid: a quick answer on a busy call night, a draft of a difficult patient message, a summary of a dense guideline document. But stars can mislead. Large language models generate text by predicting plausible word sequences, not by verifying truth, and they can produce confident, fluent, entirely fabricated content — the phenomenon known as hallucination. A resident who consults an AI system at three in the morning may be consulting something that sounds authoritative and is wrong in ways that are difficult to detect without exactly the expertise the trainee is still developing.

The study’s authors situate their work within a growing but still thin body of evidence. Previous research by Cervantes and colleagues, published in the Journal of Investigative Medicine in 2024, examined medical educators’ perceptions of generative AI and found a profession divided — intrigued by the technology’s potential, wary of its risks to rigor and to the development of clinical reasoning. A 2025 review in the New England Journal of Medicine by Abdulnour, Gin, and Boscardin went further, proposing educational strategies for the clinical supervision of AI use itself, arguing that supervising how trainees engage with AI should become as routine as supervising how they prescribe medications or interpret electrocardiograms. The Pittsburgh survey adds empirical ground truth to that theoretical framework by asking what is actually happening in one large academic center.

The stakes of the question extend beyond individual competence into the architecture of medical training itself. Residency is built on graduated responsibility: interns perform supervised tasks, seniors direct teams, attendings hold ultimate accountability. Generative AI scrambles this hierarchy in an unfamiliar way, because it gives the most junior member of the team access to something resembling expert-level output without any guarantee of expert-level accuracy. A 2023 randomized vignette study published in JAMA by Jabbour and colleagues measured this directly, testing whether AI assistance improved diagnostic reasoning for hospitalized patients — and found that the benefits were neither automatic nor uniformly distributed, underscoring that how the tool is deployed matters as much as whether it is deployed at all.

There is also a subtler cognitive risk that the study’s framework acknowledges: the phenomenon of cognitive offloading. Research published in the journal Societies in 2025 by Gerlich examined how reliance on AI tools correlates with diminished engagement in critical thinking, a finding with obvious resonance for a profession whose core skill is precisely disciplined, skeptical reasoning. If a trainee learns to accept an AI-generated differential diagnosis without interrogating it, the technology may quietly erode the very habit of mind that residency exists to build. Conversely, if trainees are taught to treat AI output the way they treat a consultant’s recommendation — as an informed opinion to be weighed, checked, and integrated — the technology could sharpen rather than soften clinical judgment. Which outcome prevails depends heavily on the norms that faculty model and programs codify, which is exactly why measuring both groups’ behaviors matters.

The Pittsburgh team’s design reflects that dual focus. By surveying trainees and faculty within graduate medical education at the same institution, the researchers could capture the full supervision chain: the people most likely to reach for these tools and the people responsible for evaluating the work those tools touch. Portions of the work were presented as a poster at the University of Pittsburgh Graduate Medical Education Connect Conference in February 2026 and as a plenary session at the medical center’s Department of Research Day in May 2026, before the full paper was accepted on August 13, 2026 and published online on August 31, 2026. The authors report no funding and no competing interests, and the study involved no patients or protected health information, sparing it the privacy entanglements that often complicate clinical AI research. In a move that strengthens the study’s transparency, the datasets generated and analyzed are publicly available in the Harvard Dataverse repository, allowing other researchers to interrogate the findings independently.

What makes this study resonant beyond academic medicine is the broader economic and social evidence it aligns with. A widely discussed 2023 field experiment by Dell’Acqua, McFowland, Mollick, and colleagues described the performance of AI on knowledge work as a jagged technological frontier: tasks on one side of an invisible boundary are transformed by AI assistance, while superficially similar tasks just beyond it see little benefit or outright harm. Medicine sits squarely astride that frontier. Drafting administrative text and surfacing literature are tasks where generative models excel; nuanced diagnostic reasoning under uncertainty remains stubbornly human. The problem, as the Pittsburgh survey implicitly frames it, is that trainees and faculty may not agree on where the boundary lies — or may not know it exists at all.

The study’s ultimate contribution may be less a single statistic than a reframing of institutional responsibility. Sailing by the stars served generations of navigators well, but only because the stars’ positions were meticulously cataloged, their small motions understood, and their limitations respected. Generative AI in medical training deserves the same treatment: not prohibition, not blind adoption, but rigorous charting of where it helps, where it misleads, and what competencies trainees must retain regardless of how capable the tools become. The Pittsburgh team — clinicians embedded in the very training environment they studied — have supplied one of the careful navigational fixes the field now needs. As residency programs across the country confront trainees already carrying these tools in their pockets, the question the study poses is no longer whether graduate medical education will engage with generative AI, but whether it will do so with a map or by guesswork.

Subject of Research: Generative AI use among graduate medical education trainees and faculty physicians

Article Title: Sailing by the Stars: A Cross-Sectional Survey Study of Generative AI Use Among GME Trainees and Faculty

Article References: Vasilakis, G. M., McSurdy, K. E., Berlacher, K., & Stokes, N. (2026). Sailing by the Stars: A Cross-Sectional Survey Study of Generative AI Use Among GME Trainees and Faculty. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10751-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10751-6

Keywords: generative artificial intelligence, graduate medical education, medical education, residency training, survey study, clinical supervision, physicians, large language models, cognitive offloading, academic medicine, Journal of General Internal Medicine, hallucination

The study, led by Di Hu and colleagues, surveyed 203 pediatric residents at a single tertiary teaching hospital in 2026 using a structured questionnaire covering demographics, training motivation, training quality, professional identity, work stress, psychological status, and social support. Nearly three quarters of the respondents, 72.91 percent, were women, reflecting the heavily female composition of China’s pediatric trainee population. The researchers analyzed the responses with descriptive statistics and used logistic regression to identify which factors were independently associated with negative emotional states, a methodological choice that allows them to separate real predictors of distress from mere correlations.

On the surface, the training itself looks solid. A striking 94.09 percent of residents reported having adequate opportunities for clinical practice, and 93.11 percent said they were satisfied with the quality of teaching they received. For a training program cranking out the next generation of children’s doctors, those are encouraging numbers. The technical machinery of residency, the ward rotations, the supervised procedures, the didactic teaching, appears to be functioning largely as designed. If the goal were simply to teach residents how to practice pediatrics, the system would seem to be succeeding.

But the numbers underneath tell a far darker story. Only 23.65 percent of residents said they felt proud of their pediatric career, and just 55.66 percent were willing to commit to pediatrics long term. Most alarmingly, 74.38 percent had considered leaving the profession or changing careers altogether. In other words, three out of every four trainees in this cohort had seriously weighed walking away from pediatric medicine, the very field China desperately needs them to enter and stay in.

The mental health data help explain why. Seventy point nine four percent of residents reported experiencing negative emotions over the preceding three months. Anxiety was the most common, affecting 57.64 percent of respondents, followed by burnout at 42.86 percent and depression at 18.72 percent. These are not trivial rates. Burnout at nearly 43 percent among trainees who have not yet even entered independent practice suggests that the stressors are baked into the training environment itself, not merely a byproduct of seniority or caseload accumulation over years.

When the researchers asked residents what was driving this distress, three stressors dominated. High workload was cited by 76.35 percent of respondents. Tense patient-physician relationships, a well-documented problem in Chinese healthcare where distrust and occasional violence against clinicians have eroded the doctor-patient relationship, affected 69.95 percent. And 67 percent pointed to a mismatch between their income and their effort, a complaint that carries particular weight in pediatrics, historically one of the lowest-paying specialties in Chinese hospitals.

The logistic regression analysis sharpened the picture by identifying which factors independently predicted negative emotions after adjusting for other variables. Residents who perceived insufficient social recognition of their profession had 2.89 times the odds of reporting negative emotions compared with those who did not, a finding that was statistically significant at p equals 0.012. Low professional pride more than doubled the odds, with an adjusted odds ratio of 2.44 at p equals 0.030. High workload raised the odds by 2.34 times at p equals 0.027. The pattern is coherent: residents who feel unseen, undervalued, and overworked are the ones drowning emotionally, and these three drivers reinforce one another in a feedback loop that erodes both identity and wellbeing.

What residents themselves want changed is telling. Compensation and benefits topped the list, with 77.34 percent naming it as a priority for improvement. Training content optimization came second at 60.59 percent, and psychological support was third at 46.31 percent. The ranking makes intuitive sense: you cannot fix burnout with mindfulness workshops when the underlying grievances are financial and structural. The authors argue that urgent interventions are needed on multiple fronts, including salary reform, psychological support infrastructure, optimization of training content, career development services, and enhanced social recognition of pediatricians as a profession.

The findings carry implications well beyond a single training base in Chongqing. Pediatric workforce shortages are a global phenomenon, driven in many countries by low pay relative to other specialties, high emotional demands, and litigious or strained family interactions. The Chinese data add a specific warning: even when the educational quality of training is high, a program can fail at retention if it ignores professional identity and mental health. A resident who learns excellent pediatric medicine but graduates feeling underpaid, unrecognized, and emotionally exhausted is not a success story for the health system.

The study has limitations worth noting. It is a cross-sectional survey from a single center, so the 203 respondents represent one snapshot at one institution rather than a nationally representative sample, and the design cannot establish causation between the identified factors and psychological distress. The authors also note that the study was reviewed by the Institutional Review Board of the Children’s Hospital of Chongqing Medical University, which granted an exemption from formal ethical review because the survey was anonymous, low-risk, and involved no clinical intervention or patient data. Still, the scale of the reported distress, three quarters of trainees considering career exit, is hard to dismiss as an artifact. If China wants more pediatricians, the survey’s message is blunt: better teaching will not be enough. The country will have to make pediatric careers worth staying in, with pay that matches the workload, psychological support that trainees actually use, and a society that treats children’s doctors as the essential professionals they are.

Subject of Research: Mental health, professional identity, and training quality among pediatric residents in China

Article Title: Current status and recommendations for pediatric residency training: a cross-sectional survey of 203 residents from a single training base in China

Article References: Hu, D., Hu, Y., Fan, Y., Yang, Z., Tang, X., Li, M., & Pan, B. (2026). Current status and recommendations for pediatric residency training: a cross-sectional survey of 203 residents from a single training base in China. BMC Medical Education. https://doi.org/10.1186/s12909-026-10632-w

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10632-w

Keywords: pediatrics, residency training, burnout, mental health, professional identity, physician workforce, China, medical education, social support, workforce shortage, anxiety, compensation

The review arrives at a moment of explosive growth in surgical simulation. Orthopedic surgery, perhaps more than any other operative discipline, depends on psychomotor skills that are notoriously difficult to acquire through observation alone. Arthroscopic procedures, in which surgeons maneuver a camera and instruments through tiny incisions while watching a monitor, require hand-eye coordination that bears little resemblance to open surgery. Traditionally, trainees developed these skills on cadavers, which are expensive and anatomically variable, or gradually on live patients under supervision, an approach that raises obvious ethical and safety concerns. VR simulators promised a third path: unlimited, consequence-free practice on anatomically realistic virtual joints, complete with haptic feedback that lets the trainee feel the resistance of tissue and the click of a meniscal repair device.

Mohammdi and her coauthors conducted a structured scoping review, following the PRISMA-ScR reporting guidelines, to identify studies investigating VR-based orthopedic education. Rather than pooling data statistically, the team synthesized findings narratively and organized them along several axes: the type of procedure being taught, the simulation modality employed, the training level of the participants, and, crucially, the Kirkpatrick model of educational outcomes. That framework, developed in the late 1950s and still the gold standard for evaluating training programs, grades evidence in ascending tiers, from learner reaction at level one, through knowledge and skill acquisition at level two, behavioral change in real settings at level three, and finally measurable results for patients and institutions at level four. Where studies fall on this ladder tells you almost everything about the maturity of the field.

What the researchers found was a literature that has grown rapidly in recent years but remains heavily concentrated in one anatomical niche. Arthroscopy-based applications dominate the field, with knee and shoulder procedures accounting for the vast majority of published work. This concentration makes sense from a technical standpoint: arthroscopic simulators benefit from well-defined tasks, such as diagnostic knee arthroscopy or meniscal resection, that can be scored objectively using metrics like instrument path length, economy of movement, and time to completion. Platforms typically measure how smoothly a trainee navigates the virtual joint, whether they respect tissue boundaries, and how their performance improves across repeated sessions. Yet the concentration also reveals a blind spot. Fracture fixation, spine surgery, joint arthroplasty, and pediatric orthopedics remain comparatively underrepresented in the simulation literature, leaving large portions of orthopedic practice without equivalent virtual training infrastructure.

The technological picture that emerged from the review is one of pragmatic compromise. Most systems described in the literature were semi-immersive rather than fully immersive, meaning trainees manipulated physical instruments while viewing a computer-generated operative field on a screen, rather than wearing a head-mounted display that surrounds them entirely in a synthetic environment. Semi-immersive arthroscopic simulators have an advantage in that they preserve the physical ergonomics of real surgery, where the surgeon’s hands hold actual instruments while the eyes track a monitor. The participants in most studies were orthopedic residents, the trainees at the stage of training where simulation offers the greatest marginal benefit, since they possess foundational medical knowledge but lack the procedural fluency that only repetition can build.

On the question of effectiveness, the evidence clusters firmly at the lower rungs of the Kirkpatrick ladder. The overwhelming majority of studies assessed simulator-based skill acquisition, corresponding to Kirkpatrick level two, demonstrating that trainees who practice on VR platforms do indeed get better at the tasks those platforms present. Many of these studies also showed that performance gains followed recognizable learning curves, with novices improving rapidly over the first several sessions before plateauing, a pattern that allows educators to define proficiency benchmarks. Some research went further and established construct validity, the demonstration that a simulator can reliably distinguish between experienced surgeons and novices, a prerequisite for using such devices in high-stakes assessment. The reviewers note that immersive VR systems and higher-fidelity platforms showed promising results in skill acquisition and, in a limited number of cases, genuine skill transfer to the clinical environment.

That phrase, limited number of cases, sits at the heart of the review’s central critique. Studies assessing whether simulator-trained skills transfer to actual operating rooms, let alone whether they improve patient outcomes, were relatively few. This is not a trivial gap. Skills psychologists have long documented that expertise acquired in one context can fail to generalize to another, particularly when the simulated environment diverges from clinical reality in subtle ways: the tactile feedback of real tissue, the variability of patient anatomy, the cognitive load of managing a live surgical team, and the consequences of error. A trainee may achieve flawless scores on a virtual knee arthroscopy yet struggle when the camera fogs, the patient bleeds, or the anatomy deviates from the textbook. Without level-three and level-four evidence, the profession cannot say with confidence that hours in the simulator translate into safer, faster, or more successful operations.

Compounding the transfer problem is what the reviewers describe as substantial heterogeneity across the field. Technologies vary widely in fidelity, from basic desktop arthroscopy trainers to sophisticated haptic platforms costing tens of thousands of dollars. Validation methods differ from study to study, outcome measures are inconsistent, and there is no standardized framework that would allow educators to compare one simulator against another or to certify proficiency in a way that carries across institutions. This fragmentation has practical consequences. A hospital investing in simulation technology currently has limited rigorous evidence to guide purchasing decisions, and a residency program designing a VR curriculum must essentially build its own validation study before trusting the results. The authors argue that future research should prioritize standardized validation frameworks, pursuit of higher-level educational outcomes, and deliberate integration of simulation into real surgical practice, rather than accumulating yet more demonstrations that trainees improve on the devices they practice on.

The trajectory of the field nonetheless points toward broader adoption. Declining hardware costs, improvements in graphics rendering and haptic engineering, and the integration of artificial intelligence for automated performance assessment are converging to make VR training more accessible and more informative than ever. The review’s authors also acknowledge the role of modern tools in their own workflow, noting that they used large language models solely for language refinement and readability enhancement, with all content critically appraised and edited by the authors themselves. As simulation programs mature, the realistic near-term vision is a blended curriculum in which residents reach demonstrable proficiency on virtual platforms before ever touching a real joint, with simulators serving as gatekeepers rather than mere supplements. For that vision to be fully credible, however, the field must produce the studies it has so far avoided: longitudinal trials tracking simulator-trained surgeons into their clinical practices, with outcomes measured not in simulator scores but in operative times, complication rates, and patient recovery.

The scoping review thus functions as both a progress report and a challenge. It confirms that virtual reality has earned a legitimate place in early-stage orthopedic training, particularly for arthroscopic skills in the knee and shoulder, where the evidence of educational benefit is now robust enough to inform curriculum design. At the same time, it exposes a profession that has validated its teaching tools without yet proving their ultimate purpose. Surgery is ultimately measured in outcomes for living patients, not scores on a screen, and the next generation of research must cross that bridge. Until it does, virtual reality in orthopedic education remains a powerful rehearsal space, enormously valuable for building competence, but still awaiting its final examination on the stage that matters most.

Subject of Research: Virtual reality simulation for orthopedic surgical education and training

Article Title: Educational applications of virtual reality in orthopedic surgery: a scoping review of effectiveness and future directions

Article References: Mohammdi, S., Abbasnejad-Ardehroudkenari, M., Langari, A. A., Jafari, M., Ghodous, S., Amouzadeh-Lichahi, M., & Haghi, B. P. (2026). Educational applications of virtual reality in orthopedic surgery: a scoping review of effectiveness and future directions. BMC Medical Education. https://doi.org/10.1186/s12909-026-10385-6

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10385-6

Keywords: virtual reality, orthopedic surgery, medical education, surgical simulation, arthroscopy, scoping review, Kirkpatrick model, skill transfer, haptic feedback, residency training, validation frameworks, Educational

The target of their critique and their pedagogical advice is SEP-1, the Severe Sepsis and Septic Shock Early Management Bundle, a federally mandated quality measure built around a prespecified set of interventions. The bundle requires blood cultures, broad-spectrum antibiotics, lactate measurements, and defined intravenous fluid dosages, all enacted under a strict timeline after severe sepsis or septic shock has been established. Hospitals must adhere to every element of the protocol to receive credit, although there are allowances for documented exclusions, such as a fluid goal not met because of decompensated heart failure. Introduced by the Centers for Medicare and Medicaid Services in 2015, SEP-1 has taken on new weight as it transitioned from a pay-for-reporting measure to a pay-for-performance measure in fiscal year 2026. More than 3,000 hospitals participating in the CMS Hospital Value-Based Purchasing Program now face financial rewards and penalties tied to their SEP-1 performance, and for larger institutions those quality scores can swing millions of dollars in Medicare payments.

The stakes of that reimbursement link ripple directly into the training wards, because clinicians and health systems often apply the full SEP-1 protocol to any patient in whom sepsis is even a consideration rather than risk a compliance failure. Distinguishing sepsis from severe sepsis and septic shock in real time is notoriously difficult and depends on technical definitions, so the safest institutional strategy is broad application of the bundle. The premise of value-based purchasing is that standardizing care will reduce morbidity and mortality, but researchers have questioned the asserted benefit of SEP-1, citing real-world studies that challenge its impact on mortality in undifferentiated sepsis presentations. A 2025 systematic review in Annals of Internal Medicine examined the effect of SEP-1 compliance and implementation on sepsis mortality, and other analyses have found that compliance is associated with improved outcomes for septic shock but not for severe sepsis. Nonetheless, as Zapata and Dhaliwal emphasize, the compliance-reimbursement link has been forged, and it is now the daily reality for hospitals, and therefore for the residents and teachers who work inside them.

What makes SEP-1 different from the financial considerations educators have long folded into their teaching? Documentation requirements to support billing are a well-established part of residency education, a tacit acknowledgment of insurance reimbursement realities, and teaching high-value care similarly asks educators to weigh costs when discussing tests and treatments with trainees. SEP-1 differs by rigidly coupling time-sensitive clinical actions to financial and reputational outcomes for the institution. It is more complex than predecessor quality metrics, and its measurement is substantially more burdensome. It compels extra work such as explaining counterintuitive clinical actions, like the additional 250-milliliter fluid bolus in the opening vignette, or documenting the rationale for mundane omissions, such as why a second lactate level was not measured. Compounding the problem, the very subject of the measurement, sepsis, is a heterogeneous, complex, and contested syndrome whose definitions and best practices continue to evolve, which means the bundle’s fixed 2015-era requirements can conflict with current evidence, including modern recommendations to avoid blood cultures in non-severe pneumonia.

To show how deep those conflicts run, the authors construct a detailed teaching case: a 92-year-old man arrives with lethargy, cough, and dyspnea, a fever of 38.4 degrees Celsius, a heart rate of 108, and a blood pressure of 88 over 58. He weighs 63 kilograms and carries a history of heart failure with an ejection fraction of 25 percent, stage 3 chronic kidney disease, chronic urinary obstruction managed with an indwelling catheter, a prior Pseudomonas urinary tract infection, and recent Clostridioides difficile colitis. His lactate is 2.2 millimoles per liter, his urinalysis shows pyuria, and a respiratory viral panel comes back positive for influenza A. The electronic medical record fires a sepsis alert, establishing time zero, based on suspected infection, two systemic inflammatory response syndrome criteria, and organ dysfunction. After one liter of normal saline and acetaminophen, his temperature, heart rate, blood pressure, and mental status all improve within 90 minutes, and no antibiotics have been given.

Walking through the bundle element by element, the attending in the case demonstrates what the authors call threading the needle. Blood cultures before antibiotics align completely with standard practice, so no extra justification is needed. Broad-spectrum antibiotics within three hours only partially align with clinical judgment: the rapid improvement without antibiotics supports influenza as the likely diagnosis, the pyuria may be a chronic finding rather than acute infection, and reflexive antibiotics carry the risk of recurrent C. difficile colitis, so the attending openly weighs watching the patient for a few hours against the protocol’s three-hour window. The initial lactate has limited prognostic value in this context but fulfills the metric. The repeat lactate required within six hours because the first value exceeded 2.0 directly conflicts with the evidence, which does not support using lactate changes to guide therapy, and the attending asks the resident to call the admitting team, explain that the test is needed for metrics purposes, and document the order. Meanwhile, the ward nurse or inpatient physician must explain to a sleeping, improving patient and his family why an extra blood draw is needed at 2 a.m.

The fluid requirement generates similar friction. The bundle stipulates 30 milliliters per kilogram of crystalloid for patients with hypotension, which for this patient would mean roughly 1.9 liters, yet a single liter has already rendered him euvolemic, and more fluid poses a real risk of hypervolemia given his severe heart failure and advanced kidney disease. The attending instructs the resident to document the rationale for deviating from the stipulated amount so the team is not penalized on sepsis auditing, and to explain the decision to the bedside nurse, who is herself well versed in the sepsis protocol. Each deviation demands timestamping, documentation, and cross-team communication, the invisible administrative labor that SEP-1 generates even when clinicians act entirely appropriately. The authors argue that these moments should not be hidden from trainees but narrated aloud, so that learners can see precisely where clinical reasoning, evidence-based care, and protocol requirements overlap, diverge, or collide.

Beyond real-time narration, the authors describe how post hoc reflection consolidates these lessons and connects protocol-driven actions to broader professional responsibilities. One approach ties bundle-aligned actions to a larger goal that transcends a single patient: an educator might explain that the intensive care unit’s funding last year was contingent on performance on a few CMS metrics, so the patient in front of them may not need the ICU now, but another patient will in six months. Another reframes metrics as instruments for quality improvement rather than compliance, as when an attending describes how benchmarking revealed that the hospital’s heart failure readmissions stemmed from missed goal-directed therapy before discharge, a shortcoming the attending also recognized in their own practice. Faculty can also name a metric’s flaws while clarifying its purpose, sharing stories in which a sepsis alert prompted blood cultures that seemed excessive but later returned positive and changed care, or cases in which weight-based fluid resuscitation, a contested practice with limited supporting evidence, caused harm. Inviting discussion of where SEP-1 fails and where it helps encourages trade-off thinking rather than absolutism, a dialectical habit that transfers to other clinical contexts.

The perspective lands at a moment when pay-for-performance sepsis measurement has become a flashpoint in American medicine, with a joint position paper from major infectious disease and emergency medicine societies already calling for reform of electronic quality measures. Zapata and Dhaliwal’s contribution is neither a defense of SEP-1 nor a call for open defiance, but a practical pedagogy for living inside an imperfect system. When trainees perceive pressure to prioritize institutional objectives over patient care, skepticism and confusion arise, and educators who stay silent risk teaching cynicism by omission. The authors’ proposed stance is candid acknowledgment of a metric’s limitations alongside honest articulation of its utility to patients, clinicians, and institutions. The objective, they write, is not uncritical adherence but the thoughtful demonstration of how to maintain clinical judgment and professional integrity while working within mandates that will not wait for the evidence to settle. Medical educators, on this view, must guide learners through today’s system while preparing them to shape tomorrow’s.

Subject of Research: Teaching clinical judgment alongside the CMS SEP-1 sepsis quality bundle in medical education

Article Title: Teaching to the Test: Threading the Needle on Sepsis Quality Metrics

Article References: Zapata, J., & Dhaliwal, G. (2026). Teaching to the Test: Threading the Needle on Sepsis Quality Metrics. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10710-1

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10710-1

Keywords: sepsis, SEP-1, quality metrics, medical education, pay-for-performance, CMS, clinical judgment, value-based purchasing, residency training, health systems science, evidence-based medicine, sepsis bundle

The study, led by Bin’e Wang, Mei Lu, and Ming Tao of the Affiliated Hospital of Zunyi Medical University, together with colleagues at Zunyi Medical University, took a deliberately close-up look at the psychological experiences of resident trainees enrolled in China’s mandatory standardized residency training program. Standardized residency training, known as SRT, is the compulsory pathway through which every newly graduated physician in China must pass before practicing independently. Trainees commonly face heavy workloads, low remuneration, ambiguous professional identity, psychological stress, and burnout, yet most prior research has treated these burdens as if they were uniform across the entire training period. Few studies have compared psychological experiences across training stages, even though the challenges trainees confront and the support they need vary substantially from one stage to the next.

To capture that variation, the researchers employed a descriptive phenomenological design, a qualitative approach rooted in the philosophy of phenomenology, which seeks to describe lived experience exactly as participants perceive it rather than through the lens of pre-existing theory. Using purposive sampling, the team selected 33 resident trainees at different stages of training from a tertiary Grade A hospital, the top tier of China’s hospital classification system and a setting where trainees encounter some of the most demanding clinical environments, including intensive care units. Each trainee participated in a semi-structured interview, a format that follows a prepared interview guide while allowing participants to raise unexpected themes in their own words. The interviews were transcribed with the assistance of the AI transcription feature of Tencent Meeting, used only for preliminary text conversion; the authors then manually proofread every sentence against the recordings and bear full responsibility for the content.

The researchers analyzed the interview data using Colaizzi’s seven-step method, a rigorous qualitative analysis framework that moves from reading the transcripts and extracting significant statements to formulating meanings, clustering themes, and validating the resulting themes against the original accounts. The analysis, reported in accordance with the Standards for Reporting Qualitative Research, yielded three core themes that together describe a staged psychological trajectory rather than a unitary or static experience.

The first theme traced the phased accumulation of self-efficacy, the psychological construct describing a person’s belief in their own capacity to execute the behaviors needed to perform successfully. In the earliest stage of training, residents described positive experiences that built this confidence from the ground up: first successful procedures, first reassuring evaluations from supervisors, first moments when a patient’s condition improved under their watch. Self-efficacy accumulated gradually, fed by mastery experiences and social persuasion, until it reached a point of stable maintenance in later stages, when trainees no longer questioned whether they belonged in the hospital but instead relied on established routines to carry them through clinical demands. The trajectory suggests that early training is a critical window in which psychological foundations are laid, and that positive early experiences are not merely pleasant but structurally necessary for the confidence residents will draw on for years.

The second theme revealed an inverse psychological relationship between subjective well-being and job burnout across the training stages. Subjective well-being, the scientific term for how people evaluate their own lives in terms of positive feelings and satisfaction, declined as training progressed, while burnout emerged and intensified. Burnout, in the occupational psychology literature, is characterized by emotional exhaustion, depersonalization, and a diminished sense of accomplishment, and it is a recognized hazard in medical training worldwide. The study’s trainees described a pattern in which the early idealism and energy of the first stage gave way to declining well-being and the emergence of burnout in later stages, a reversal that the researchers describe as inverse psychological experiences of well-being and job burnout. This finding is technically significant because it implies that burnout is not simply the residue of an exhausting first year; it can deepen precisely when trainees are expected to be most competent and most independent, at the very point when programs typically reduce supervision and psychological support.

The third theme concerned professional identity and development, charting a movement from idealistic identification to realistic confusion. In the early stage, trainees identified strongly with the idealized image of the physician, embracing the profession’s prestige and purpose with something approaching enthusiasm. As training advanced and they confronted the realities of the job, including heavy workloads, low remuneration, and the ambiguous professional identity that China’s trainees commonly report, that idealistic identification eroded into realistic confusion. Trainees questioned what kind of doctor they were becoming, what the profession actually offered them, and whether the identity they had entered training to assume still matched the person emerging from it. Professional identity, in the vocational psychology literature, is the integration of one’s self-concept with the values, norms, and role expectations of a profession, and its destabilization is a known risk factor for attrition and mental health problems in medical trainees.

Taken together, the three themes support the study’s central conclusion: the psychological experiences of resident trainees during standardized residency training are phased rather than unitary or static. Confidence builds in stages, well-being and burnout move in opposite directions across stages, and professional identity transforms from idealism to confusion as the realities of the profession replace its ideals. Because the challenges and support needs vary by stage, clarifying stage-specific experiences is essential for designing targeted interventions, improving training quality, and protecting trainees’ mental health. A support system calibrated to the first stage, when self-efficacy is fragile and idealism is high, would look very different from one calibrated to the later stages, when burnout deepens and identity confusion sets in.

The researchers argue that standardized residency training management should therefore pursue two goals simultaneously: cultivating clinical competence and establishing a phased psychological support system, so as to optimize trainees’ psychological experiences and promote positive psychological feelings. In practical terms, that could mean pairing early-stage residents with supervisors who provide frequent mastery experiences and encouragement, monitoring well-being and burnout longitudinally rather than at a single point, and offering identity-focused mentoring in later stages when realistic confusion is most likely to take hold. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Affiliated Hospital of Zunyi Medical University, with participants’ privacy strictly protected and all records anonymized. It was supported by the Zunyi Medical University Innovation and Entrepreneurship Training Program, and the authors declare no competing interests.

For the global medical community, the study offers a technical framework with viral potential: the idea that residency is not one psychological experience but several, each with its own hazards and its own remedies. As health systems worldwide confront physician burnout, attrition, and a widening mental health gap among trainees, the message from this qualitative study is clear. If programs want residents to emerge as confident, well, and professionally grounded physicians, they must stop treating the training years as a single block and start reading them as a staged journey, intervening at each stage with the psychological support that stage demands. The 33 trainees who shared their experiences despite demanding clinical schedules made that message possible, and their openness may reshape how training programs think about the minds behind the white coats.

Subject of Research: Stage-specific psychological experiences of resident trainees in standardized residency training

Article Title: Stage-specific psychological experiences of resident trainees in standardized residency training: a qualitative study

Article References: Wang, B., Lu, M., Ji, J., Gao, F., Wang, H., Yuan, Y., & Tao, M. (2026). Stage-specific psychological experiences of resident trainees in standardized residency training: a qualitative study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15858-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15858-4

Keywords: residency training, physician burnout, mental health, medical education, qualitative research, professional identity, self-efficacy, subjective well-being, Stage-specific, psychological, experiences, resident

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

Competency-based medical education, including the Canadian version known as Competence by Design, was built on a compelling promise: training should align tightly with the observable tasks of a discipline, and assessment should capture what trainees can actually do. Entrustable Professional Activities, or EPAs, define the essential tasks of each specialty and anchor workplace-based assessment. The framework has improved clarity, feedback, and the connection between training and independent practice. But the perspective argues that implementation has created a practical incentive with an unintended consequence: programs now prioritize settings where specialty-specific competencies can be most readily observed and documented, and off-service rotations, where such observations are harder to coordinate, become structurally vulnerable.

The technical heart of the argument lies in what the authors reviewed. They examined the Competence by Design EPAs for pediatrics, emergency medicine, and internal medicine and found that many could be achieved through specialty-specific clinical experiences alone. From an assessment standpoint, observing a trainee within her primary specialty environment is simply more straightforward than coordinating EPA observations across services. The result is a quiet restructuring of educational time: programs ask whether experiences once obtained through off-service rotations could instead be delivered within home services, simulation environments, longitudinal experiences, or academic curricula. In some cases, the authors acknowledge, such redesign genuinely improves efficiency and removes experiences no longer essential to contemporary practice. The problem is what falls through the cracks.

What falls through the cracks, the perspective contends, is a form of learning that extends well beyond discipline-specific competence. Off-service rotations were never designed only to expose trainees to additional medical content. They served as opportunities to develop broader clinical judgment, encounter uncommon clinical presentations, understand the operational realities of adjacent specialties, and build the relationships that support future collaborative practice. Evidence supports this broader view. A study by Diffley and colleagues demonstrated measurable gains in clinical understanding following a one-month off-service plastic surgery rotation, framing the allocation of resident time as a cost-benefit decision in which educational breadth must be weighed against opportunity costs. Their findings suggest that clinical exposure itself, rather than curricular content alone, drives meaningful learning and may enable knowledge transfer across specialties.

The social infrastructure of care may be the most underappreciated casualty. Research by Chan and colleagues identified familiarity as a central mechanism influencing referral and consultation interactions among residents. Familiarity emerged through repeated exposure over time: rotating through other services, shared educational experiences, collaborative patient care, and even informal interactions outside clinical work. Residents reported that knowing colleagues personally increased receptivity, empathy, and willingness to engage in discussion and debriefing after consultations. Familiarity was closely tied to trust, as repeated interactions allowed physicians to develop an understanding of one another’s practice styles and clinical reasoning. Shared experiences also created alignment of interests and improved communication efficiency during patient transfers. Off-service rotations, in this light, function not merely as educational exchanges but as mechanisms for developing the interpersonal relationships that allow healthcare systems to coordinate care effectively.

To make sense of what may be changing, the authors deploy a conceptual lens borrowed from human factors engineering: the Systems Engineering Initiative for Patient Safety, or SEIPS 3.0 framework. SEIPS conceptualizes healthcare as a system of interacting people, tasks, technologies, environments, and organizational structures that shape care processes and outcomes. Crucially, it recognizes that healthcare work occurs through interconnected physical, cognitive, and social or behavioral processes. From the physical process perspective, cross-disciplinary experiences expose residents to diverse environments, workflows, operational structures, technologies, and patterns of patient movement across the system. A resident on an off-service rotation encounters different approaches to triage, consultation, discharge planning, escalation of care, documentation, and referral, developing a broader awareness of how healthcare systems function across boundaries.

The cognitive dimension is equally consequential. Different specialties prioritize different information, operate with different thresholds for intervention, and conceptualize patient problems in distinct ways. Participating in these environments helps residents develop more flexible mental models and appreciate that similar clinical presentations can lead to different but equally appropriate approaches to care, depending on context. The social and behavioral dimension completes the picture: healthcare depends on communication, coordination, role negotiation, and shared understanding across individuals and teams. Working alongside other residents and faculty allowed trainees to become familiar with professional cultures, consultation practices, service expectations, and the day-to-day realities of adjacent specialties, shaping future interactions in subtle but important ways. The educational question, reframed through SEIPS, is whether redesign unintentionally narrows the physical, cognitive, and social processes through which residents learn to participate in complex healthcare systems.

The concern is not hypothetical. Residents within EPA-based systems have reported that predefined assessment structures may not fully capture the complexity, breadth, and contextual nature of clinical work, and have expressed worries that emphasizing specialty-specific EPAs could diminish learning opportunities occurring outside directly assessed activities. The authors also point to systems-level evidence: a study by Saffo and colleagues showed that placing an internal medicine triaging resident in the emergency department reduced preventable admissions while significantly improving trainee experiences related to patient flow and initial management. Off-service clinical roles, that work suggests, can simultaneously enhance medical training and healthcare system efficiency by fostering interdisciplinary collaboration and expanding competencies in triage and care transitions. Patients, after all, rarely experience healthcare through the boundaries of specialties; they move across services, teams, and settings throughout their care journey.

The perspective is careful to avoid arguing against competency-based training, EPAs, or educational redesign. Its constructive proposal is that programs should identify and preserve forms of learning that become less visible within outcome-based models, not because they lack value but because their outcomes are harder to document directly. The authors outline concrete opportunities: longitudinal cross-disciplinary experiences, integrated clinics, structured patient-following activities across services, joint academic half-days, cross-specialty simulation, collaborative case reviews, intentional consultation experiences, and assessment activities that explicitly recognize systems-oriented and collaborative skills. They cite a promising example from Clark and colleagues, who described recurring combined educational sessions between emergency medicine and internal medicine residents built around shared clinical problems and transitions of care. Residents valued the shared experience itself as much as the educational content, reporting increased understanding of colleagues’ working conditions, recognition of shared goals, and appreciation for opportunities to discuss common frustrations and collaboratively identify solutions.

The deeper implication reaches beyond residency offices into the architecture of medical training itself. Little empirical work has examined how off-service and cross-disciplinary experiences have actually changed following implementation of outcomes-based training models, how curricular restructuring decisions are made, or which educational outcomes may be affected by these changes. The authors, whose work was supported in part by the Social Sciences and Humanities Research Council of Canada, invite clinicians and educators to consider not whether to preserve prior rotation models, but how to preserve the elements of cross-disciplinary exposure that remain essential for preparing clinical learners for practice. As training systems evolve, educational leaders may benefit from asking not only whether competencies are achieved, but also what forms of learning become more or less available through curricular redesign. In a healthcare system where collaboration across specialties determines patient outcomes, the perspective suggests, the invisible curriculum of familiarity, trust, and systems awareness may be worth more than any single assessed task.

Subject of Research: Medical Education

Article Title: Preserving the Educational Value of Off-Service and Cross-Disciplinary Experiences in Competency-Based Residency Training

Article References: Bilgic, E., Zarandi, A., Athina (Tina) Martimianakis, M., Ngo, Q. N., Fleming, A., & Martin, L. (2026). Preserving the Educational Value of Off-Service and Cross-Disciplinary Experiences in Competency-Based Residency Training. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10808-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10808-6

Keywords: residency training, competency-based medical education, off-service rotations, cross-disciplinary learning, SEIPS framework, postgraduate medical education, Preserving, Educational, Value, Off-Service, Cross-Disciplinary, Experiences

The research team measured breast cancer screening compliance during calendar year 2025 using tools embedded in the EPIC electronic health record system. Patients were counted as compliant if they were women aged 40 to 74 who had received a mammogram within the previous two years and had no disqualifying characteristics, such as a prior bilateral mastectomy. The investigators then abstracted detailed patient data from the medical record and collected information about each physician, including gender, language facility, and years in practice. Using both bivariate comparisons and multivariable logistic regression, they teased apart how much of the screening gap could be explained by patient characteristics, clinical and utilization patterns, and physician attributes.

The headline numbers are striking. Of the 8,825 patients eligible for breast cancer screening at the practice, 1,024 — about 12 percent — were cared for by residents. Faculty physicians achieved a screening rate of 83 percent among their eligible patients, while residents reached only 66 percent, a difference that was highly statistically significant. In the unadjusted analysis, a resident’s patient had just 0.41 times the odds of being up to date on screening compared with a faculty patient — a 95 percent confidence interval of 0.35 to 0.47, meaning resident-panel patients were roughly 60 percent less likely to have a current mammogram.

But the raw gap tells only part of the story, and this is where the study becomes technically interesting. The resident and faculty panels were not comparable populations to begin with. Faculty panels included a higher percentage of patients who were white, spoke English, and carried commercial insurance, along with more medical comorbidities. The resident panel, by contrast, contained more patients with serious mental illness and had fewer primary care encounters overall. These differences matter enormously, because decades of research have shown that screening mammography rates vary systematically with race, ethnicity, socioeconomic status, language, and engagement with the health care system.

To account for this, the researchers built a series of progressively more rigorous statistical models. In the first model, adjusting only for patient sociodemographic characteristics, the odds ratio for a resident patient being screened improved from 0.41 to 0.50. When clinical and utilization variables were added in the second model, the odds ratio rose further to 0.59. And in the third model, which incorporated physician attributes such as gender, language facility, and years in practice, the odds ratio climbed to 0.73 — with a confidence interval of 0.54 to 0.98 that only barely excludes the null. In other words, most of the apparent screening deficit attributable to being a resident’s patient dissolved once the underlying differences between patient populations were taken into account, though a meaningful residual gap remained.

This pattern of attenuation carries an important message about how quality disparities in teaching practices should be interpreted. Earlier studies comparing resident and faculty care have often reported that trainees achieve poorer cancer screening rates, and some have framed this as a conflict between training and equity. A 2019 study in the same journal documented disparities in quality of primary care by resident and staff physicians, and a multi-center study published in 2025 confirmed differences in ambulatory care outcomes between trainees and faculty across institutions. But those studies, like this one, must grapple with the fact that resident panels are not random samples of the practice population. Residents often inherit panels of patients with the greatest social and medical complexity — patients who are harder to reach, less likely to attend appointments, and more likely to face logistical barriers to preventive care.

The setting of the new study makes its findings particularly notable. The authors deliberately chose to examine this question in an academic primary care practice with robust practice support, reasoning that if residents’ disadvantages in experience and continuity could be overcome anywhere, it would be in a high-functioning environment. Teaching practices like this one typically offer embedded care managers, screening outreach programs, and structured panel management — infrastructure that should, in theory, buffer less experienced clinicians from their own limitations. The fact that a gap persisted even under these favorable conditions suggests that the problem is not simply one of inadequate support, but may be woven into the structure of residency training itself.

One structural feature looms large: the annual turnover inherent in residency. Residents graduate and hand their panels to incoming trainees every year, creating what researchers have called the revolving door of resident continuity practice. Prior work has identified gaps in transitions of care during these year-end handoffs, and a 2009 commentary in JAMA described the academic year-end transfer of outpatients as an unaddressed patient safety issue. Patients who lose their trusted physician at a moment of transition may be less likely to follow through on screening recommendations, particularly if the handoff is poorly executed. The lower number of primary care encounters observed in the resident panel in this study may reflect both patient disengagement and the discontinuity that comes with annual rotations.

The study’s conclusion is measured but pointed: while rigorous statistical adjustment substantially improved the apparent performance of resident physicians, residency training programs may need to be redesigned to eliminate the remaining disparities in care. Possible redesigns discussed in the broader literature include longer continuous blocks in continuity clinic, structured year-end sign-out programs, and X-plus-Y scheduling models that cluster ambulatory time to protect continuity. Quality improvement efforts targeting specific screening gaps — such as a 2025 initiative addressing colorectal cancer screening disparities between faculty and residents — offer a template for how practices might close the mammography gap as well.

For patients, the practical takeaway is not to avoid resident physicians, whose care is supervised by attending faculty and whose patients often have the greatest need. Rather, the findings highlight where the health care system should direct its attention: toward the patients of trainees, who are disproportionately likely to face barriers to preventive care, and toward the design of the training programs that will produce the next generation of physicians. Breast cancer screening saves lives, and the US Preventive Services Task Force recommends biennial screening for women aged 40 to 74. Ensuring that every eligible woman — regardless of whether her physician is a first-year resident or a twenty-year veteran — receives that recommendation in time is a test of whether academic medicine can align its training mission with its equity obligations.

Subject of Research: Disparities in breast cancer screening rates between resident and faculty physicians in an academic primary care practice

Article Title: Understanding Low Breast Cancer Screening Rates by Resident Physicians

Article References: Weingart, S. N., Kufer, K. S., Short, M. I., Gillis, J., Sathi, K., Chawla, P., Schelling, K., Huang, K. T. L., & Tishler, J. (2026). Understanding Low Breast Cancer Screening Rates by Resident Physicians. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10899-1

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10899-1

Keywords: breast cancer screening, mammography, resident physicians, primary care, health disparities, graduate medical education, residency training, quality of care, continuity of care, academic medicine, preventive care, logistic regression