Objectives In 2019, Rheumatology in Canada transitioned to competency-based medical education (CBME), mandating the development of competence committees (CCs). CCs interpret aggregated assessment data about residents to inform decisions about learner progress and achievement. In the psychology literature, groups are generally thought to make better decisions than individuals by generating more ideas, drawing on broader perspectives, and reducing errors. Evidence suggests that heterogeneous groups—when supported by robust rules and procedures—are more likely than homogeneous groups to consider a broader range of options leading to higher-quality decisions.[1] While equity, diversity, and inclusion (EDI) are increasingly emphasized, little is known about how CCs in internal medicine and its subspecialties consider and enact diversity in their membership and deliberations. Methods We conducted a qualitative study using semi-structured interviews with 18 CC members and chairs from 6 Canadian universities. All participants were drawn from internal medicine or its subspecialties, including 2 from Rheumatology. Interviews explored perspectives on diversity, committee composition, decision-making rules, and fairness. Data were transcribed, coded in NVivo™, and analyzed thematically, with reflexive dialogue across a multidisciplinary research team informing interpretation. Results Five themes emerged. (1) Diversity beyond demographics: Ethnicity was rarely considered; instead, committees emphasized variation in academic rank, practice site, life stage, or assessment philosophy. (2) High agreement and collegiality limited structured decision-making: Consensus was easily reached, though participants acknowledged risks of groupthink. (3) Integrating context and diversity considerations: Committees valued contextual and anecdotal data, particularly regarding international medical graduates and equity-deserving residents. (4) Awareness sparked by reflection, but training absent: Few had received CC-specific EDI training; interviews prompted recognition of this gap. (5) CBME as aspirational but burdensome: CC responsibilities were widely viewed as resource intensive. Conclusion Cultural diversity was rarely prioritized, reflecting both structural limitations and resource constraints. CCs valued multiple forms of diversity and recognized the risks of excessive cohesion. Decision-making was typically consensus-driven and collegial but concerns about groupthink and lack of formal decision rules persisted. Efforts to incorporate contextual information aimed to promote fairness but lacked consistent safeguards against bias. As CBME continues to evolve, CCs must balance cohesion with diversity, efficiency with deliberation, and objectivity with contextual fairness. Achieving this will require local innovations—such as bias training, deliberate diversification, and explicit decision rules—alongside broader systemic reform to ensure fair, defensible, and developmentally oriented assessment for all learners. References [1.] Stahl G. J Int Bus Stud 2010;41:690-709.

Health professions educators frequently seek to study their curriculum (e.g., a new or revised curriculum for a degree-granting program, a component of that curriculum, or a stand-alone course). Despite local enthusiasm, curriculum-focused studies are often hard to publish and have been repeatedly discouraged. Yet, few authors have proposed practical solutions. The purpose of this article is to articulate common problems with curriculum research and to propose specific ways in which curriculum research can be accomplished (and published) successfully. The authors define "research" as the rigorous, systematic pursuit of new knowledge with the intent to disseminate findings in a peer-reviewed forum. They delineate 5 problems with curriculum-focused research as it is typically done: redundancy (failing to build on prior research), context-specificity, confounding and dilution, superficiality (using data sources of convenience), and conceptual obscurity (failing to employ a relevant conceptual framework). To address these problems, they encourage researchers to stop focusing on their local curriculum and instead join and contribute meaningfully to a global scholarly conversation. Engaging in a scholarly conversation involves listening to the conversation (the literature) to understand what is already known, identifying a gap the researcher can fill with a useful observation, and asking and answering a question that other people will find relevant (to their own local needs), novel (not already known), insightful (shedding light on future action), and credible (well-supported by chosen methods). The authors outline 6 prototypical potentially successful curriculum-focused research studies, including quantitative and qualitative approaches, and cite published examples. They also highlight studies to avoid. They conclude by discussing practical considerations: appraisal of research quality, funding of education research, accessing and acquiring needed research skills, measuring provider behaviors and patient outcomes, ethical issues associated with learners as study participants, and tensions between basic and applied research.

PURPOSE:Medical school grading has implications for student well-being, motivation, equity, and residency selection. However, despite more than 50 years of debate, there remains no consensus on whether grading should be tiered or pass/fail, particularly in core clerkships. This scoping review examines conceptual arguments, empirical data, and knowledge gaps regarding tiered versus pass/fail grading in medical school. METHOD:OVID MEDLINE, Embase, Web of Science, and ERIC were searched on November 15, 2023, for articles published from 2000 to 2023 focused on (1) conceptual arguments regarding tiered versus pass/fail grading in U.S. medical schools and/or (2) empirical data relevant to this debate. Two reviewers independently assessed eligibility. The authors performed meta-synthesis to group arguments into domains and cross-reference them with relevant data, appraising empirical studies using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS:Forty articles met inclusion criteria, including 22 empirical studies of variable quality (MERSQI scores, 8.5-13.5 of 18). Conceptual arguments and empirical data spanned 10 domains. Better-supported arguments included the association of pass/fail preclerkship grading with improved short-term well-being and preserved academic performance, the low reliability of individual tiered grades, and racial and ethnic disparities in clerkship grading. Areas of uncertainty included the effects of pass/fail clerkship grading on well-being, motivation, learning, and achievement; potential stress displacement with pass/fail grading; validity of tiered clerkship grades; residency application concerns; and subinternship grading considerations. CONCLUSIONS:Significant controversy about grading exists across 10 domains. Cross-cutting challenges include the diverse purposes of grading leading to conflicting opinions and data interpretations, limited study quality, and overreliance on opinion over data or theory. Recommendations include caution when interpreting small numbers of tiered grades, transparency and research regarding potential clerkship grading disparities, and consideration of all relevant dimensions in system-level assessment approaches. The authors hope these steps encourage assessment that benefits learners and patients.

PURPOSE:Stereotype threat (fear of fulfilling negative stereotypes about one's group) hinders performance through mechanisms such as overwhelming working memory and forcing conscious attention to normally automated cognitive or physical processes. Efforts to combat stereotype threat may include threat mitigation (reactive responses to identity threats) and identity safety (proactively empowering individuals to be their authentic selves). The authors assessed the relationship among stereotype threat, threat mitigation, identity safety, and participant demographics. METHOD:In this cross-sectional study, all U.S. nephrology fellows were invited to complete a survey after the 2024 national in-training examination. The study was anchored in QuantCrit, a research paradigm that applies critical race theory to quantitative methods, and included 8 items using a 5-point Likert scale. The authors performed confirmatory factor analysis to explore statistical validity for the proposed model. Exploring stereotype threat as the dependent variable, the authors compared non-QuantCrit with QuantCrit analysis. RESULTS:Overall, 646 of 962 fellows responded (66.9% response rate). With confirmatory factor analysis, a 3-factor model achieved best fit. Participants endorsed low stereotype threat (mean [SD], 1.47 [0.87]), moderate threat mitigation (mean [SD], 3.02 [1.25]), and high identity safety (mean [SD], 4.34 [0.81]). In non-QuantCrit and QuantCrit regressions, threat mitigation was positively associated with stereotype threat, whereas identity safety was inversely associated with stereotype threat. Non-QuantCrit analysis showed no identity-based differences in stereotype threat. QuantCrit analysis with disaggregated identity categories showed that Southeast Asian and Black fellows and international medical graduates (IMGs) from Asia and the Middle East had higher stereotype threat. Asian and Black fellows who were IMGs had less stereotype threat than their racial counterparts from U.S. allopathic schools. CONCLUSIONS:Fellows who experienced more identity safety reported less stereotype threat, whereas fellows who experienced more threat mitigation reported more stereotype threat. QuantCrit analysis demonstrated intergroup differences not apparent in non-QuantCrit analysis.

Importance: Increasing underrepresented in medicine (URIM) physicians among historically underserved communities helps reduce health disparities. The concordance of URIM physicians with their communities improves access to care, particularly for American Indian and Alaska Native, Black, and Hispanic or Latinx individuals. Objectives: To explore county-level racial and ethnic representation of US internal medicine (IM) residents, examine racial and ethnic concordance between residents and their communities, and assess whether representation varies by presence of academic institutions or underserved settings. Design, setting, and participants: This retrospective cross-sectional study collected data from the Association of American Medical Colleges, Accreditation Council for Graduate Medical Education (ACGME), Area Health Resources Files, and US Department of Education data on ACGME-accredited US IM residency programs and their associated county populations. Self-reported racial and ethnic data from 2018 for 4848 residents in 393 IM programs in 205 counties were used. Data were analyzed between February 15 and September 20, 2024. Exposure: County-level presence for academic health centers (AHCs), minority-serving institutions (MSIs), health professional shortage areas (HPSAs), and rurality. Main outcomes and measures: Main outcomes were representation quotients (RQs) or the ratio of the proportion of IM residents and their concordant county-level racial and ethnic populations. Quantile linear regression models on median representation were used to identify the association with URIM, Asian, and White residents by US Census division and county-level AHCs, MSIs, HPSAs, and rurality. Results: Among 4848 residents, 4 (0.08%) self-identified as American Indian or Alaskan Native, 1709 (35.3%) as Asian, 289 (6.0%) as Black, 211 (4.4%) as Hispanic or Latinx, 2 (0.04%) as Native Hawaiian or Other Pacific Islander, and 2633 (54.3%) as White. A total of 761 (15.7%) were classified as URIM. Among URIM groups, American Indian and Alaska Native (mean [SE] RQ, 0.00 [0.04]), Black (mean [SE] RQ, 0.09 [0.20]), Hispanic and Latinx (mean [SE] RQ, 0.00 [0.04]), and Native Hawaiian and other Pacific Islander (mean [SE] RQ, 0.00 [0.26]) residents were grossly underrepresented compared with their training sites' county-level representation. Fifty-one of 205 counties (24.8%) with IM programs had no URIM residents. Black and Hispanic or Latinx residents had higher representation in counties with more MSIs (mean [SD] RQ, 0.19 [0.24]; P = .04; mean [SD] RQ, 0.15 [0.04]; P < .001, respectively), and Hispanic or Latinx residents were less represented in counties with more AHCs (mean [SD] RQ, 0.00 [0.06]; P < .001). Asian residents had lower RQs in counties with more MSIs (mean [SD] RQ, 6.00 [0.65]; P < .001), and White residents had higher representation in counties with greater presence of AHCs (mean [SD] RQ, 0.77 [0.04]; P = .007). Conclusions and relevance: In this cross-sectional study, URIM IM residents remained underrepresented compared with their program's county populations. These findings should inform racial and ethnic diversity policies to address the continuing underrepresentation among graduate medical education physicians, which adversely impacts the care of historically underserved communities.

Background While residents play a critical role as teachers in the clinical learning environment, knowledge of how they develop the necessary skills to teach and how graduate medical education programs can support their development as teachers remains limited. Objective This study aims to use the pedagogical content knowledge framework to explore how residents' workplace-based experiences influence their development as clinical teachers. Methods This qualitative study used focus groups and semistructured interviews with senior residents across departments of emergency medicine, general surgery, and internal medicine at the University of California, San Francisco. We used purposive sampling to recruit participants. Twenty-five residents agreed to participate. We interviewed participants based on availability and ceased data collection when we stopped identifying new concepts. We conducted 2 focus groups and 13 interviews with 18 participants, with data collection occurring between July 2023 and March 2024. The authors used thematic analysis with pedagogical content knowledge as a sensitizing concept to identify themes. Results The authors identified 3 themes characterizing how residents learn to teach through their workplace-based experiences: learning from being a learner, developing teaching skills through experience, and gathering and responding to feedback. The process of residents' development as teachers was largely similar across all 3 specialties. Differences in the specific experiences that shaped residents' development were influenced by specialty-specific workplace demands and differences in practice contexts. Conclusions Residents' development as clinical teachers occur through the integration of their experiences as learners, expanding clinical and teaching expertise, and feedback and reflection on their ongoing teaching practice.

Abstract In this article, the authors propose a repurposing of the concept of entrustment to help guide the use of artificial intelligence (AI) in health professions education (HPE). Entrustment can help identify and mitigate the risks of incorporating generative AI tools with limited transparency about their accuracy, source material, and disclosure of bias into HPE practice. With AI’s growing role in education-related activities, like automated medical school application screening and feedback quality and content appraisal, there is a critical need for a trust-based approach to ensure these technologies are beneficial and safe. Drawing parallels with HPE’s entrustment concept, which assesses a trainee’s readiness to perform clinical tasks—or entrustable professional activities—the authors propose assessing the trustworthiness of AI tools to perform an HPE-related task across 3 characteristics: ability (competence to perform tasks accurately), integrity (transparency and honesty), and benevolence (alignment with ethical principles). The authors draw on existing theories of entrustment decision-making to envision a structured way to decide on AI’s role and level of engagement in HPE-related tasks, including proposing an AI-specific entrustment scale. Identifying tasks that AI could be entrusted with provides a focus around which considerations of trustworthiness and entrustment decision-making may be synthesized, making explicit the risks associated with AI use and identifying strategies to mitigate these risks. Responsible, trustworthy, and ethical use of AI requires health professions educators to develop safeguards for using it in teaching, learning, and practice—guardrails that can be operationalized via applying the entrustment concept to AI. Without such safeguards, HPE practice stands to be shaped by the oncoming wave of AI innovations tied to commercial motivations, rather than modeled after HPE principles—principles rooted in the trust and transparency that are built together with trainees and patients.

Assessment for Learning (AFL) includes all educational activities designed to improve teaching and learning through gathering, sharing, and acting on information. AFL expands on the concept of formative assessment—which focuses mainly on an in-the-moment assessment activity—to include all processes that facilitate teachers and learners actively seeking and interpreting evidence to guide learning. AFL involves teachers and learners as partners and uses evidence to identify what the learner needs to learn (planning), review where the learner is in their learning (observing), and strategize how to maximize learning (supporting). 1 We provide the following guidelines for teachers to implement AFL within these 3 phases of a learning activity. Teachers should tailor their choice of AFL strategies to suit their relationship with the learner and learning environment context, aiming to support the development of self-regulated learning and metacognitive skills.

BACKGROUND:Medical students can experience a range of academic and non-academic struggles. Coaching is a valuable strategy to support learners, but coaches describe working with struggling learners as taxing. Transformative learning theory (TLT) provides insights into how educators grow from challenging experiences to build resilience. This study explores how coaches evolve as educators through supporting struggling students. METHODS:This qualitative study grounded in an interpretivist paradigm used interviews of longitudinal medical student coaches at two academic institutions. Interviews, using TLT as a sensitizing concept, explored coaches' experience coaching struggling learners. We performed thematic analysis. RESULTS:We interviewed 15 coaches. Coaches described supporting students through multi-faceted struggles which often surprised the coach. Three themes characterized coaches' experiences: personal responsibility, emotional response, and personal learning. Coaches shouldered high personal responsibility for learners' success. For some, this burden felt emotional, raised parental instincts and questions about maintaining boundaries with learners. Coaches evolved their coaching approach, challenged biases, and built skills. Coaches learned to better appreciate the learner point of view and employ resources to support students. DISCUSSION:Through navigating learner struggles, educators can gain self-efficacy, learn to understand learners' perspectives, and evolve their coaching approach to lessen their personal emotional burden through time.

Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs – outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners’ needs, teaching focused on competencies, and programmatic assessment – enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner’s background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner’s success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.

What equity, diversity and inclusion issues are commented upon by Med Educ's reviewers? This commentary offers an analysis and recommendations for authors, reviewers and editors alike.

ABSTRACT:ChatGPT has ushered in a new era of artificial intelligence (AI) that already has significant consequences for many industries, including health care and education. Generative AI tools, such as ChatGPT, refer to AI that is designed to create or generate new content, such as text, images, or music, from their trained parameters. With free access online and an easy-to-use conversational interface, ChatGPT quickly accumulated more than 100 million users within the first few months of its launch. Recent headlines in the popular press have ignited concerns relevant to medical education over the possible implications of cheating and plagiarism in assessments as well as excitement over new opportunities for learning, assessment, and research. In this Scholarly Perspective, the authors offer insights and recommendations about generative AI for medical educators based on literature review, including the AI literacy framework. The authors provide a definition of generative AI, introduce an AI literacy framework and competencies, and offer considerations for potential impacts and opportunities to optimize integration of generative AI for admissions, learning, assessment, and medical education research to help medical educators navigate and start planning for this new environment. As generative AI tools continue to expand, educators need to increase their AI literacy through education and vigilance around new advances in the technology and serve as stewards of AI literacy to foster social responsibility and ethical awareness around the use of AI.

PURPOSE:Coaching in medical education facilitates learners' growth and development through feedback, goal-setting and support. This study explored how coaching relationships evolve throughout medical school and the impact of longitudinal coaching relationships on medical students' approach to feedback and goal setting in the clinical years.METHOD:In this qualitative study using a constructivist paradigm, authors purposively sampled 15 senior medical students at University of California, San Francisco, to participate in individual semi-structured interviews (October-November 2021). The authors used an inductive approach to thematic analysis.RESULTS:The authors identified four themes: First, the student-coach relationship deepened over the course of medical school. Second, students identified factors that sustained and strengthened the student-coach relationship over time: a strong foundation to the relationship, the non-evaluative nature of the relationship, coach supportiveness and responsiveness, and coach knowledge of the institutional landscape. Third, coaches provided individualized advice, assessed trajectory, and guided feedback interpretation. Lastly, students applied skills of soliciting and responding to feedback and creating learning goals, originally learned through coaching experience.CONCLUSIONS:Coaching relationships, grounded in trust, evolve to meet students' changing needs as they grow into physicians. Students apply feedback and goal-setting skills learned with the coach in clinical settings with other supervisors.

Problem: Medical students experience racial and sociopolitical trauma that disrupts their learning and wellbeing. Intervention: University of California, San Francisco (UCSF) School of Medicine students advocated for a systems approach to responding to traumatic events. Students partnered with educators to introduce an innovative protocol that affords short-term flexibility in curricular expectations (e.g., defer attendance, assignments, assessments) to empower students to rest, gather, or pursue community advocacy work. This study explored students' protocol utilization and student, staff, and faculty experience with its implementation. Context: UCSF is a public medical school with a diverse student body. Students raised the need to acknowledge the effects of trauma on their learning and wellbeing. Consequently, students and educators created the UCSF Racial and Sociopolitical Trauma protocol ('protocol') to allow students time-limited flexibility around academic obligations following events anticipated to inflict trauma on a school community level. The protocol affords students space to process events and engage with affected communities while ensuring all students achieve school competencies and graduation requirements. Impact: We conducted a two-phase mixed methods study: (1) retrospective analysis of quantitative data on students' protocol use and (2) focus groups with students, staff, and faculty. We used descriptive statistics to summarize students' protocol use to adjust attendance, assignment submission, and assessments and thematic analysis of focus group data. Across eight protocol activations June 2020 - November 2021, 357 of 664 (54%) students used it for 501 curricular activities: 56% (n = 198) for attendance, 71% (n = 252) for assignments, and 14% (n = 51) for assessments. When deciding to utilize the protocol, student focus group participants considered sources of restoration; impact on their curricular/patient responsibilities; and their identities. The protocol symbolized an institutional value system that made students feel affirmed and staff and faculty proud. Staff and faculty initially faced implementation challenges with questions around how to apply the protocol to curricular components and how it would affect their roles; however, these questions became clearer with each protocol activation. Questions remain regarding how the protocol can be best adapted for the clerkship setting. Lessons Learned: High protocol usage and focus group data confirmed that students found value in the protocol, and staff and faculty felt invested in the protocol mission. This student-initiated intervention supports a cultural shift beyond diversity toward trauma-informed medical education. Partnership among learners and educators can contribute to transforming learning and healthcare environments by enacting systems and structures that enable all learners to thrive.

Abstract Although most students complete Step 1 before clerkships, some institutions delay the exam until after clerkships. The change to pass/fail grading adds additional complexity that should be considered when deciding about exam timing. Both early and late administration may affect learning outcomes, learner behavior, student well-being, and residency match success. Step 1 completion before clerkships promotes learning outcomes (e.g., integration and mastery of foundational material), may encourage students to focus on the curriculum, and may better prepare students for clinical science exams (CSEs). However, delaying the exam ensures that students maintain foundational knowledge and may encourage clinical educators to demonstrate basic science illustrations. An early Step 1 may affect learner behavior by allowing clerkship students to focus on clinical learning. The associated National Board of Medical Examiners performance report may also be used for Step 2 and CSE preparation. However, delaying Step 1 allows greater scheduling flexibility based on developmental milestones. Administration of Step 1 before clerkships removes a significant stressor from the clinical year and decompresses the residency application period. However, a delayed Step 1 reduces the pressure on students to engage in numerous extracurricular and research activities to distinguish themselves due to the pass/fail change. An early Step 1 exam may also lead to improved CSE performance, which is often linked to clerkship honors criteria, an increasingly valuable distinction for residency match success after the change to pass/fail. In contrast, delaying Step 1 is associated with higher first-time pass rates, which may be especially important for students at risk for failure. Medical educators and students should collaboratively approach the question of Step 1 timing, considering these factors within the context of the medical school program, curricular constraints and priorities, and students’ individual needs and goals.

Purpose Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training. Method A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most. Results Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner’s patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students. Conclusions This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.

We thank the authors of the Letter to the Editor (Kassam et al. 2023) for raising excellent points about our scoping review (Hamza et al. 2023). Our goal with this work was to offer a synthesis and mapping of literary conversations about CBME since 1978 as both a resource and a prompt for further conversations about multiple aspects of competency-based medical education (CBME). The letter authors share that in their own program, ‘those who identified as men felt much better prepared for the transition to CBME than those who identified as women.’ We suggest that gender differences in perception of preparedness are likely more related to persistent findings regarding to confidence gaps between men and women (Ehrlinger and Dunning 2003) than to actual preparation or issues specifically related to CBME. However, the authors do raise an important point about observed risks of gender inequity in assessment. This issue highlights the critically important need for ongoing monitoring for bias in assessment related to gender or other learner characteristics to inform strategies to counteract inequity in all learner assessment, including CBME programs (Klein et al. 2019). We agree with the letter authors’ concerns about the risks of reductionism and implementation issues overshadowing the larger goals of CBME to ensure desired outcomes of training. Attention to assessing and monitoring the progress of all learners, not just those in difficulty, is a core feature of CBME design (van Melle et al. 2019). The letter authors also identify ‘a significant omission regarding the individual and societal impacts of CBME.’ We have analyzed and mapped the societal and individual impact of CBME in the article, with more details included in Supplementary Appendix C (Hamza et al. 2023), and we believe this content draws important focus to the larger goals of CBME to balance with the attention to implementation concerns. We agree with the letter authors about the unfortunate lack of sufficient research into the societal impacts of CBME to date. We propose a challenge to leaders across disciplines to balance vision and strategy with tactics and management as they implement and/or evaluate CBME in their contexts.

Assessing learners is foundational to their training and developmental growth throughout the medical education continuum. However, growing evidence shows the prevalence and impact of harmful bias in assessments in medical education, accelerating the urgency to identify solutions. Assessment bias presents a critical problem for all stages of learning and the broader educational system. Bias poses significant challenges to learners, disrupts the learning environment, and threatens the pathway and transition of learners into health professionals. While the topic of assessment bias has been examined within the context of measurement literature, limited guidance and solutions exist for learners in medical education, particularly in the clinical environment. This article presents an overview of assessment bias, focusing on clinical learners. A definition of bias and its manifestations in assessments are presented. Consequences of assessment bias are discussed within the contexts of validity and fairness and their impact on learners, patients/caregivers, and the broader field of medicine. Messick’s unified validity framework is used to contextualize assessment bias; in addition, perspectives from sociocultural contexts are incorporated into the discussion to elaborate the nuanced implications in the clinical training environment. Discussions of these topics are conceptualized within the literature and the interventions used to date. The article concludes with practical recommendations to overcome bias and to develop an ideal assessment system. Recommendations address articulating values to guide assessment, designing assessment to foster learning and outcomes, attending to assessment procedures, promoting continuous quality improvement of assessment, and fostering equitable learning and assessment environments.

The transition from medical school to residency in the United States consumes large amounts of time for students and educators in undergraduate and graduate medical education (UME, GME), and it is costly for both students and institutions. Attempts to improve the residency application and Match processes have been insufficient to counteract the very large number of applications to programs. To address these challenges, the Coalition for Physician Accountability charged the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) with crafting recommendations to improve the system for the UME-GME transition. To guide this work, the UGRC defined and sought stakeholder input on a "blue-skies" ideal state of this transition. The ideal state views the transition as a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias. This manuscript uses polarity thinking to analyze 3 persistent key tensions in the system that require ongoing management. First, the formative purpose of assessment for learning and growth is at odds with the use of assessment data for ranking and sorting candidates. Second, the function of residents as learners can conflict with their role as workers contributing service to health care systems. Third, the current residency Match process can position the desire for individual choice-among students and their programs-against the workforce needs of the profession and the public. This Scholarly Perspective presents strategies to balance the upsides and downsides inherent to these tensions. By articulating the ideal state of the UME-GME transition and anticipating tensions, educators and educational organizations can be better positioned to implement UGRC recommendations to improve the transition system.