Christina M. Vitto

Purpose: Competency committees use group decision-making procedures to determine when learners may advance in their training. These committees have been well-described in graduate medical education (GME) and efforts have explored transferability of this model to undergraduate medical education (UME). Existing research in UME has focused on committee structure and member perspectives, with little examination of decision-making processes. This study explored how UME competency committees use group decision-making to arrive at competency determinations. Method: This theory-informed, multi-institutional ethnographic study was conducted at 7 medical schools in the United States between 2023 and 2024. Participants were members of each medical school’s competency committee. Data sources included observations of committee deliberations and member interviews. The authors analyzed data using an abductive approach, combining inductive and deductive reasoning with theory to formulate an understanding of group decision-making. Effective group process, a theoretical model for group-decision making in GME, served as the primary lens for analysis. Results: A total of 20 competency committee meetings were observed, during which 242 students were discussed. Committees formulated their decisions in a complex context. Factors contributing to the complexity included the existence multiple groups concerned with student performance (eg, competency committees, advancement committees), other metrics for performance (ie, grades), and academic polices. A similar stepwise process was used to make decisions across sites. However, there was significant inter-institutional variation in procedures and rules related to student presentations and deliberations, voting procedures, and the chair’s role. Outcomes were determined by locally established thresholds and decisions varied; some rendered remediation or entrustment decisions while others provided developmental feedback. Conclusions: Decision-making in the UME setting is complex with features distinct from GME. UME competency committees therefore require unique considerations to support effective group decision-making and mitigate challenges and threats to the process.

Problem: Accelerated pathway programs graduate students in 3, rather than 4, years. While these programs help address physician workforce shortage and student debt, they have not implemented rigorous assessment frameworks aligned with Competency-Based Medical Education (CBME) training to ensure students are ready to graduate 1 year early. This report describes an accelerated pathway program using a CBME framework to transition students into graduate medical education programs when they are deemed competent. Approach: Starting in 2018, the Virginia Commonwealth University School of Medicine (VCU-SOM) developed an accelerated and competency-based graduation (CBG) program focusing on competency as the standard for graduation. Students apply to the CBG program in their second year, with selection based on academic performance, program commitment, and mutual interest with the affiliated residency. Except for reduced post-clerkship elective time, students complete the same curriculum as non-CBG peers. Progress during the clinical year is evaluated by the CBG Clinical Competency Committee (CCC) to ensure students meet required milestones for advancement and eligibility for accelerated graduation. Outcomes: As of 2024, 20/33 (61%) CBG students graduated in 3 years, while the remainder (13/33; 39%) transitioned back to the standard program. CCC analysis showed increasing competency ratings, with nearly 100% achieving “competent” or “on track” in core domains. Some assessment areas showed lower competency, identifying targets for improvement. Program directors report that all CBG graduates are progressing appropriately through residency milestones, with no significant concerns about performance or burnout. Next Steps: The CBG program offers a competency-based, time-variable pathway (CBTV) from medical school to residency, utilizing a CCC and designed to support both early and traditional progression based on achievement of competency. Future steps include adapting to the removal of Step 1 scores as a selection tool, ensuring adequate Entrustable Professional Activities (EPA) data for decision-making, and expanding participation across additional specialties.

Introduction: A competency committee is a group of experts who make a consensus-based judgement about a learner’s competence. While evidence-based practices for post-graduate committees have been described, research and standards are lacking in undergraduate medical education. Medical school competency committees often distribute student reviews to individual members; therefore, understanding how they interpret assessment data is critical. Methods: Approaching our investigation from a social constructionist orientation, we conducted think aloud interviews with 22 competency committee members at 7 medical schools in the United States from 2023–2025. Participants were tasked with reviewing local student assessment data in preparation for a competency committee meeting and verbalizing thoughts to an investigator. We analyzed transcripts using an interpretivist approach, with sociocultural cognition theory as the primary interpretive lens. Results: Two major concepts depicted how participants processed student assessment data to arrive at competency determinations: contextual influences and internal reasoning processes. Contextual influences (i.e. goals, data available, and standards for interpreting the data) were outside the direct control of participants. Internal reasoning processes included: first impressions, interpreting trends, and negotiating conflicting data. Contextual influences varied and served as the lens through which participants interpreted assessment data. Discussion: This study provides the first examination into the thought processes used by medical school competency committee members to make their decisions. Participants used decision-making strategies that parallel those observed in other cognitive reasoning tasks. Contextual influences were foundational in how participants interpreted assessment data, highlighting how competence is socially constructed.

Purpose Accelerated 3-year programs (A3YPs) at medical schools were developed to address student debt and mitigate workforce shortage issues. This study investigated whether medical school length (3 vs 4 years) was associated with early residency performance. The primary research question was as follows: Are the Accreditation Council for Graduate Medical Education Milestones (MS) attained by A3YP graduates comparable to graduates of traditional 4-year programs (T4YPs) at 6 and 12 months into internship? Method The MS data from students entering U.S. medical schools in 2021 and 2022 from the 6 largest specialties were used: emergency medicine, family medicine, internal medicine, general surgery, psychiatry, and pediatrics. Three-year and 4-year graduates were matched for analysis (2,899 matched learners: 182 in A3YPs and 2,717 in T4YPs). The study used a noninferiority study design to examine data trends between the study cohort (A3YP) and control cohort (T4YP). To account for medical school and residency program effects, the authors used cross-classified random-effects regression to account for clustering and estimate group differences. Results The mean Harmonized MS ratings for the midyear and end-year reporting periods showed no significant differences between the A3YP and T4YP groups (mean [SE] cross-classified coefficient = 0.01 [0.02], P = .77). Mean MS ratings across internal medicine MS for the midyear and end-year reporting periods showed no significant differences between the A3YP and T4YP groups (mean [SE] cross-classified coefficient = −0.03 [0.03], P = .31). Similarly, for family medicine, there were no statistically significant differences between the A3YP and T4YP groups (mean [SE] cross-classified coefficient = 0.01 [0.02], P = .96). Conclusions For the specialties studied, there were no significant differences in MS performance between 3-year and 4-year graduates at 6 and 12 months into internship. These results support comparable efficacy of A3YPs in preparing medical students for residency.

Purpose of Review To review the pathophysiology, diagnosis, and the management of hypertension. Given the paucity of literature regarding the role of the observation unit in the management of hypertension, we will provide our recommendations based on our experience working in an observation unit. Recent Findings Many patients have limited access to primary care, and hypertension diagnosis often relies on office-based measurements. We will describe situations where that is not necessary to make the diagnosis. We will discuss the current non-pharmacologic treatment guidelines, the education of which should be provided to patients both in the emergency department and observation units. We will provide the current recommendations on what anti-hypertension medications can be initiated in the emergency department and observation units. Summary Hypertension is a leading cause of morbidity and mortality in the USA. The utility of an observation unit in the diagnosis and management of patients with hypertension is beneficial particularly for those with risk factors for atherosclerotic disease. An observation unit stay provides the opportunity to diagnosis hypertension, initiate lifestyle education and pharmacologic treatment if indicated, and help to arrange appropriate follow-up for ongoing management and treatment in individuals with limited access to care.

Breaking bad news is a key component of the physicians’ work. Traditionally, breaking bad news has been encouraged to be performed in person whenever possible (Monden et al. Proc (Bayl Univ Med Cent) 29(1):101–102, 2016; Nickson 2019). The common practice prior to the pandemic can be summarized by “The first rule of breaking bad news is: do not do it over the phone.” It is important to be present with the family and provide support through compassion and empathy. Until recently, virtual communication technology for serious medical discussions was rare and primarily used when compelled by circumstances such as distance. The COVID-19 pandemic has transformed our ability to deliver news in person and has required the medical community to increase the utilization of telephone and video conferencing to communicate with patients and their family members. Breaking bad news through virtual media is a new skill in need of further guidance and education regarding how to set up the conversation, provide empathy, and lend support (Wolf et al., Oncologist 25(6):e879–e880, 2020). Therefore, we have created a teaching toolbox to help educate healthcare providers on how to deliver bad news by phone or video.