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Addressing Challenges in the Transition from Medical School to ResidencyTaking Action on the UGRC Recommendations

Learning Objectives
1. Review the Coalition for Physician Accountability UME-GME Review Committee recommendations for comprehensive improvement of the UME-GME transition
2. Define the objectives and tools needed to support targeted coaching of residents for professional identity formation and growth mindset across the transition
3. Identify the steps needed to help learners develop individualized learning plans for the start of residency
4. Outline actionable next steps for moving UGRC recommendations forward considering the role of precision education
1 Credit

The transition from undergraduate medical education (UME) to graduate medical education (GME) presents many challenges, including being a discontinuous time of professional development. In 2020, the Coalition for Physician Accountability charged its UME-GME Review Committee (UGRC) with recommending solutions to challenges frequently encountered during the UME-GME transition. The committee published its 34 recommendations in 2021, but since then little progress has been made implementing the proposed solutions. In July 2023, the American Medical Association convened more than 45 national experts from across the medical education continuum to discuss several UGRC recommendations and consider practical next steps in the context of precision education. This webinar will provide participants with an overview of the UGRC recommendations, with special focus on two of those recommendations, and the practical next steps identified during the AMA’s July stakeholders meeting. This is a live event that will occur on the date and time indicated above. Click the “RSVP” button above to proceed with event registration. If you cannot attend the live event, an on-demand recording will be available.

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♪♪♪ ♪♪♪ ♪♪♪ Good afternoon, everybody. I'm John Andrews. I'm the Vice President for Graduate Medical Education Innovations here at the American Medical Association.

And I want to welcome you to today's Change MedEd webinar. I'll be moderating our panel. Today we're going to talk about addressing challenges in the transition from medical school to residency. And particularly about taking action on the recommendations of the UGRC panel. The transition from undergraduate medical education to graduate medical education presents challenges and is a discontinuous time in professional development. In 2020, the coalition for physician accountability charged its UME to GME review committee with recommending solutions to challenges frequently encountered during the UME to GME transition.

The committee published its 34 recommendations in 2021. But since then, there's been little progress implementing the proposed solutions. In July of 2023, the American Medical Association convened more than 45 national experts from across the medical education continuum to discuss several of the UGRC recommendations and to consider practical next steps in the context of precision education. This webinar will provide participants with an overview of the UGRC recommendations with a special focus on two of those recommendations and practical next steps identified during the AMA's July stakeholder meeting.

We have several objectives for this webinar. By the end of the webinar, participants should be able to review the coalition for physician accountability UGRC recommendations. They should be able to define the objectives and tools needed to support targeted coaching of residents for professional identity formation and growth mindset across the transition. Participants should be able to identify the steps needed to help learners develop individualized learning plans for the start of residency and outline actionable next steps for moving UGRC recommendations forward considering the role of precision education.

Before I introduce you to today's speakers, I would like to share that the views or opinions expressed during this webinar are those of the individuals expressing them only, not those of the AMA. The information provided during this webinar does not and is not intended to constitute legal advice. Instead, all information, content and materials provided during this webinar are for general informational purposes only. Now I'm pleased to introduce you to our speakers for today's webinar. Dr. Maya Hammoud is chief of the division of women's health and associate chair for education and professor of OB-GYN and learning health sciences at the University of Michigan medical school.

She also serves as a senior advisor in medical education innovation at the AMA. Benjamin Kinnear is associate professor of pediatrics at the University of Cincinnati College of Medicine. And Amber Pincavage is professor and clerkship director of general medicine at the University of Chicago Pritzker School of Medicine. Thank you all for taking time to join us today. Before we begin, I have a quick a couple of quick housekeeping items. During the webinar, please submit any questions you have in the chat box. We'll try to address some of those during the Q&A at the conclusion of our presentations.

And following the webinar, please take a moment to answer our short survey. It helps inform future events. We'll provide the link and a QR code at the end of the presentation. Lastly, this event link can be used to access this webinar on demand and read the transcript once the webinar is concluded. And with that, I'd like to turn the forum over to our first speaker, Dr. Maya Hammoud. Dr. Hammoud. Thank you, Dr. Andrews, and thank you all for joining us today. What I'm going to do is first, you know, as Dr. Andrews mentioned, there are a lot of challenges around the UME to GME transition in terms of obviously at this time of the year, a lot of people are thinking about residency selection.

We are in the mid of in the beginning and to mid-season of choosing residents. There are a lot of equity issues, a lot of well-being. We think about readiness for residency, diversity issues, transparency as we think about competency based medical education. So there are a lot of challenges around the transition and the Coalition for Physician Accountability is composed of a lot of the medical education organizations, ranging from the ACGME, the AAMC, the MBME.

And I think they're all listed here and you can see them and who all got together to try to address some of those challenges that we mentioned. And part of that, the coalition put together, commissioned a group of individuals, a lot of national experts to look at the transition and to identify what are some of those challenges and to put the recommendations for how do we actually address these challenges and how do we improve the transition.

And this is how the undergraduate medical education to graduate medical education review committee was put together. And those recommendations that Dr. Andrews mentioned was commissioned a report that was put together in August 2021. And that report had nine themes and thirty four recommendations. And those themes went from how do we actually collaborate across the medical education community for continuous quality improvement? Talked about diversity, equity, inclusion. How do we have trustworthy advising and definitive resource for our learners and advisors?

How do we look at outcome framework and assessment processes? How do you look at away rotations? How do we have equitable mission driven application processes while at the same time optimizing application review selection processes? How do you look at the educational continuity of resident readiness while also also maintaining health and wellness? Now, as we mentioned, we feel that there have been a little progress made in this, but we wanted to also check how you all think, how much progress we've made and why we all hear a lot about that there's bias and assessment and grading.

We thought we want to grade ourselves a little bit in those cotton, those themes. And we chose three themes that we want your help in helping us know today where we are actually. How have we done so far? So we have three polls that would like your help in. And you could either go on a Web site, slido dot com and enter the number or you can pull up your phones and scan the QR code. And we'd like you to assign for the diversity, equity and inclusion theme, which under that theme, there are best practices for recruitment and professional development. And how how are we doing on that theme?

So I'd love for you to actually give us a great recognizing again that we all have biases and assessment. So I'd like for you to take a few seconds to actually tell us how are we doing in that and in that theme. And we'll take a few seconds here to give the people the opportunity to actually vote on this. Are we doing a grade A, grade B, grade C or grade D in that domain? Again, you can either scan on your phone or on your computers. You can join at Slido dot com and enter the number 3107040.

And we'll see how. So it seems so far that about 50 percent of those who voted are giving us a grade C as a collective MedEd community. This is not us as me and John and Ben and Amber. This is us collective in the MedEd community. So it looks like we have a lot of work to do in this area still. I'm going to move to the next theme. And thank you for all those of you who voted. The next theme that I'm going to go to and it should once you join, it should actually change your normality to the next theme.

The next theme is the optimization of application, interview and selection processes since we're in the mid-season here. This has to do with how we do a virtual interviewing, the standards of interviews, including communication, how we're doing innovation in the residency application process and in limiting the number of interviews per applicant. I know that's a lot all combined under one. But again, how we're doing overall on the optimization of application, interview and selection processes. Seems we're doing slightly better here so far where we the majority of people giving us a grade B.

So that's good. We're doing a bit better under this category. We'll give it a few more seconds here before I give you the last one. And the last one has to do with with what we're being we're going to be talking about today. So it looks like the majority of people here are saying things we're doing a grade B, but still a third of people think we're doing a grade D here under this category. So the last one is under education, continuity, continuity and resident readiness. And this has to do with how do we do it? Feedback to medical schools, resident support resources.

This also include coaching by qualified educators, just in time training for incoming residents, which has to do with prep for residency courses and orientation at GME entry, which has to do with the boot camps at GME and specialty specific ILPs. I like somebody gave us a grade A. That's great. But it looks like the majority has also still given us a grade C. You know, and as I'm looking at these grades, I think that as a MedEd community for a report that a lot of all these national organizations that put a report out in August 2021 saying that these are recommendations that we are responsible for as a MedEd community to still for a lot of us to be still doing great to be getting a grade C, even though there's bias in assessment, I think we should really be thinking about how do we actually take those UGRC recommendations and really start moving them into actions.

This is why in July, as Dr. Andrews mentioned, thank you again for all those of you who voted. The AMA put together an AMA Innovations and Transition meeting where we actually tried to address some of those UGRC recommendations. We specifically looked at coaching. We looked at how do we do just in time training at how do we do effective GME orientation. And we looked at some of the graduating student performance evaluation.

And how do we also look at creating actionable next steps for moving these recommendations forward, considering the role of precision education, which has been a focus for the AMA. And we looked specifically at four of the recommendations, 27, 28, 29, and 30. 27 is around coaching, which you're going to be hearing more about from Dr. Kinnear today. 28, which is just in time training, 29, which is about the orientation, and 30 about the ILP, which you're going to be hearing more about also today from Dr. Amber Pincavage.

So and we also asked the group at that meeting to actually look at those at all the UGRC recommendations. And actually, we created a heat map on which of those could be accelerated with systems of precision education. And you'll see some of those that we discussed at that time. We asked people to rate them for which one could be helped a great deal. And you can see a lot of them actually could be helped with systems of precision education. And we're very excited to see that the attendees at that meeting actually felt that a system of precision education can accelerate, actually helping us move some of those recommendations forward into implementation.

So this is something that we feel that focusing on precision education will help some of those recommendations move into actions. And now I'm going to pass it on to Dr. Kinnear, who is going to be talking about coaching. Good afternoon. Thank you, Dr. Hammoud. Thank you, Dr. Andrews and the AMA for having me here to talk about coaching. This is a topic that has already gained a ton of steam in medical education and I think is only going to get more important as we think about reimagining what the transition from UME to GME should look like.

And things like Dr. Hammoud said with precision education and frankly, with competency based education. So let's take a dive into it. I think I want to start mostly by talking about this UGRC recommendation. I'm going to give you all a moment to read it. I'm not going to read it to you. But when I look at it, it's actually a great recommendation. I agree with everything that's on here. But one of the challenges with talking about something like coaching and with this recommendation is there are a lot of questions that are left open.

So who are these qualified educators and how do we make sure they're qualified? When should coaching actually start? Right before the transition? The beginning of med school, some other time? How will we know if lifelong learning and growth mindset and professional identity formation are happening? And how can we ensure that we keep this equitable? These are all challenges that come with kind of adopting something like coaching, a concept that actually doesn't come from medical education, but it's a concept that migrated over from the worlds of business, sports, other forms of performance like theater and music and frankly, other fields of higher education.

And this is not a thing that's specific to coaching. So many of our theories and concepts have migrated over from other fields. And as they come into our field, we have to decide how can we best adopt them and adapt them to fit our learners needs and the needs of our programs. So this is where we are with coaching. How do we take this concept that comes from other fields and bring it into our field in a way that is helpful and meaningful? Now, the good news is there's actually been a lot of work that's already been done around coaching in medical education. And here are two great resources to learn a little bit more about those. I recognize the AMA name is on both of them.

I promise you, I do not work for the AMA. These are actually resources I've been using for quite some time now. The one on the left is a handbook that is a great introduction to coaching and different approaches to coaching and frameworks. The one on the right. Oh, and by the way, the one on the left is actually a free download if you want it. The one on the right is a book that you can purchase or perhaps even access through your health sciences library. It gives you an even more in-depth look on the frameworks and approaches of coaching and some of the theories behind it. And frankly, coaching some specific learner populations that might need extra support.

So there's been a lot of great work already done on what is coaching, how can we apply it to our field? And I think this is important because one of the biggest questions that comes up whenever we talk about coaching is what is coaching and how is it different from things like mentorship and advising and counseling and things like that? So that's something I'd like to cover in the brief time I have with you today. I want to contrast coaching with two other roles that often get mixed up with coaching, an advisor and a mentor. And there's a lot of different ways we could draw the contrast. But one of my favorites is this two by two axis that comes from a book by a guy named Stephen Fairley.

And if you think of this axis where the left to right axis represents who's the expert in the conversation, who's driving the conversation? Is it the learner or is it the advisor, mentor or coach? So where do we fall on that axis? And then what's actually happening in these interactions? Is the mentor, advisor or coach giving answers at the bottom or asking questions at the top? And let's see where these different things fall. An advisor falls way over here. They are the expert. They know that they know the content. They know what you need to do. And they're going to give you a lot of answers when we go to academic advisors.

They tell us what courses we should take, what kind of mentorship we might want to seek out, what kind of study resources we might want to use. And so they are asking some questions, but mostly they're the expert and they're giving answers. When you think about mentors, it's a little more balanced in terms of asking questions and giving answers. But they generally are still the experts. We go to them for their scholarly expertise or their career guidance or something like that. So it's really driven by the mentor in terms of who's holding the power in the conversation. And again, it's a kind of even exchange of asking questions and getting answers.

When we get to coaching, I want to draw a contrast with how we colloquially use coaching. So I've had sports coaches my whole life. I played hockey. It wasn't particularly good, but I've always had hockey coaches. And my hockey coach didn't ask me how I felt about how I was performing. They mostly yelled at me and they thought they were the experts and they had all the answers. So this is where we often think of like sports coaches. But in medical education, the way our field has started to adopt coaching, it's up here in this quadrant where the learner is really driving the conversation and the coach is asking questions, not giving answers.

It's about reflective question asking. In fact, in terms of this, who is the expert? A lot of people in our field are starting to say a skilled coach does not even need to be a content expert. If you're coaching, let's say, an internal medicine resident or a medical student interested in going to OBGYN, you don't need a coach who's in that field. You just need somebody who is skilled in coaching. And so coaching is a solutions focused orientation where you ask reflective questions and the learner drives the conversation and is the expert. So here are the core tenets. You ask more than you tell. You guide the learner toward their own value based goals.

And the thing that I cannot overstate enough is relationship. You have to have relationships. It's all about guided reflection. And there are many different specific coaching frameworks out there. A very popular one is called R2C2 developed by Dr. Joan Sargent and others. There's several of them. But these three things really are at the core of what we imagine coaching to be in medical education. So why do we even need to have coaching? I think that's a really important question. And to me, the most important answer is because our learners are humans.

And so many things that we ask of them, especially around the time of transition, is really hard for humans to do. I want you to think back when you were a learner or maybe you are a learner and imagine all the things that the medical education was asking of you. We asked you to have a growth mindset, even though you're surrounded by hyper competitive peers and getting grades and you're getting ranked. We asked you to take time for reflection and metacognition, even though you're overworked and underpaid. We asked you to use your assessment data for improvement and reflection and growth, even though you knew that same data were going to be used for summative decisions about your readiness to go on or even a grade you might be getting.

We asked you to be vulnerable in the clinical learning environment, even though you knew you were constantly being assessed. And we asked you to be resilient, even though you were constantly getting hit with moral injury from trying to do the best for your patients in a broken system. We asked our learners to do all of these things. And it is really hard to stay oriented toward growth, mastery, and to gain skills that we need to be independently practicing physicians when all of these things are working against us. Coaching is a relationship based way to try to move through that and stay focused on these things that we're hoping to get like growth mindset, professional identity formation, and other things.

So we need coaching because we're human. That's the answer. What can or should coaching address? This is what I'm really excited about because I don't think we know yet where and how can coaching be best used in our field. All of these things you see on your screen, coaching has been used. Better skills, better competence, academic performance, well-being, inclusion, mindset, all of these things. But we still don't know where and how is coaching best used, especially if we all have somewhat limited resources at our institutions to implement coaching programs. We probably can't cover everything, at least not at first, but how should we prioritize? What should we prioritize?

And I think this is where there's a real opportunity as we explore how can coaching help with the transition? Where can coaching best be used and how can we do this in an evidence-based way? Now, importantly, we talked a lot in our July meeting about how we need to provide some sort of outcomes, especially to our stakeholders, because coaching takes support. It takes funding. It takes time. And we adopted this taxonomy of outcomes from a paper by Dr. Andrew Hall and colleagues as a way of thinking about what are the different outcomes we could maybe try to evaluate in terms of the impact of coaching.

So, one, we could look at learner-based outcomes and we could potentially even look at clinical outcomes. More and more people are trying to say, how does education impact clinical care? So it wouldn't be unreasonable to say, can we actually look at clinical or patient-based outcomes in terms of the impact of a coaching program? We can think about outcomes in terms of the individual level, the program level, or even the systems level, depending on how far we want to zoom in or zoom out. And then what is the timeline in terms of impact that we expect? Are we looking at short term, right around the transition, medium term, or longer term?

And you could kind of sort these different pieces together to form different measures. You could have a long term individual level learner outcome. You could have a medium term program level outcome for the education program or even for a clinical program. All these different things. And as we choose amongst this kind of mishmash of measures, which ones we might want to seek out first, I think we should use a lot of theory. So rather than just seeing what sticks, we should say what theories around learner growth and learning and motivation that we have would say these are the outcomes that we would expect to see change.

We should use the evidence that we have to guide us because there have been studies to show the impact of coaching programs for medical learners. And it should totally be co-created with our learners rather than us saying these are the outcomes we're going to study. We should ask them, what are the outcomes that are important to you? Because really they are the end users of this coaching program if you think about it. And to do this work, we talked a lot about how we might want to get some help. So if most of us live in that yellow circle there as an educator or a coaching expert, maybe we should look to our program evaluation colleagues or implementation scientist colleagues to see if we can do this as well as possible and make the connection between our programs and our outcomes as clear as possible.

Because if we work here and we leave out the implementation scientists, then we don't know if we've implemented things correctly and any outcomes we have, we don't know if it's because of low fidelity implementation or if it's because the program didn't work. If we live over here, then we lose sight of the alignment between the program that we're doing and the outcomes that we care about. And we might have that misalignment and not see the connection that we're looking for. And if we live up here, then obviously we lose our North Star because we're not including our educators and our learners. So I think this is where the future of coaching lies in terms of understanding where can coaching best be used to support our learners, especially around the time of transition with all those different options in terms of what and how we focus on.

So if you take nothing else away from this, remember coaching, it is a relationship based, reflective question asking practice that can help our learners in multiple different domains of growth. And we still have a lot to learn, but this is where the opportunity lies moving forward around the transition. Thank you very much. And with that, I'm going to turn it over to Dr. Pincavage, who's going to talk about individualized learning plans, which are a key component of coaching programs. Thank you so much, Dr. Kinnear. And good afternoon, everyone. I'm excited to talk about something that I'm very passionate about and summarize what our group talked about at the meeting this summer.

Next slide. So as mentioned, the UGRC made a recommendation number 30 that students reflect on their performance and then create a specialty specific individualized learning plan to be presented to their residency program to start off their residency training. Next slide. So what are individualized learning plans? Well, if you look at the literature, what has been advocated when they've been described is that they should be part of an ideal educational handover from medical school to residency.

And the goal of them is to guide continued improvement of the learner. They should be learner driven and identify areas for improvement in goals and should be co-produced by the learner and the coach or advisor. So not entirely done alone because learners do need help with self-reflection. They should be then used to guide the transition to residency education and acted upon so that improvement can happen and can help residency programs provide the necessary supports that are needed as their learners transition into their program.

So far, there's been one multi-center pilot of an educational handover with an ILP that was completed in pediatrics that's been described in the literature. And then there's also been a national ILP pilot completed in maternal medicine, which I collaborated on with a lot of other educators. Next slide. So in our group, we talked about why is this important and why should we be working on this recommendation? And what we discussed was that, well, this could improve patient safety.

It could lower mistrust during the transition between UME and GME. It could promote collaboration in education. And with the learners, it could enhance well-being and preparedness as people go through this challenging time. It can also facilitate making a true continuum of education, which we already discussed has been more disjointed, and increase engagement of learners in the process and help them build skills for lifelong learning and growth mindset. And also, it would allow us to address unique needs of learners.

Next slide. So we discussed what are challenges to creating a robust ILP system throughout our education. And there are several things that are getting in the way. The implications of feeding forward information about learners can be complicated and tricky because you don't want to bias future thoughts about them. Also, the residency selection process is very time consuming and you don't want to get in the way of that or prevent people's chances.

Equity is a problem, a challenge as well. Also, how to do this with international medical graduates and include them when they have a very different system and ability to do these. The mistrust is a challenge. Resources that would be available to do this and also variability in different medical schools and specialties. What could facilitate this? Well, certainly technology could if we had technology that was shared, support from national specialty organizations, having LCME requirements that this needs to be done by medical schools, having sharing of best practices.

And then also for GME to give feedback to UME would facilitate this process as well so we know how we're doing. And faculty development is important. Next slide. And so what could be the potential impact if there were more robust individualized learning plans occurring in this transition? Well, firstly, at the learner level, as mentioned earlier, we could enhance self-directed learning and then improve resilience, a growth mindset and self reflection and lifelong learning. And also during this transition, improve confidence and competence of our learners.

In the education system, we could have more effective handoffs in the UME to GME transition. We could have learner centered competency based education, which we're all striving for and have some shared metrics and data. And in the health care system, there's the potential to improve patient outcomes and care, to increase trust and also to have more retention of our learners and actually meet their needs. So we are remediating and helping them along the way. And we aren't losing people throughout the process.

Next slide. So what resources would be required? So we heard a lot about coaching. So you need coaches to do that. Also technology, having a shared mental model of what competencies we are looking for, having support from accrediting bodies and national organizations, having research around this. And also support for international medical graduates will be very important. And also to address the application inflation and match process.

And so that's not so time consuming. And we can really reimagine the last year of medical school to have people start thinking about what they need for the transition and acting before it, even before they make the transition. Next slide. So we also in our group discussed what next steps we think would be important to make a standardized ILP or an ILP process more nationally. We were pressed to actually give a timeline for this. I didn't share that with you.

It was very challenging to give it a timeline. But what we said was that we needed to first gather best practices and background from any individualized learning plan projects that are currently ongoing. We also need to, as educators, identify shared UME to GME competencies that have a shared mental model. We did note that the AAMC is already starting to work on this with a bunch of leaders. And we were very much hoping that that would be completed so we could use that.

Also, next to describe specialty specific expectations for entering residency as well. And then it would need to be socialized and gather buy in from stakeholders and learners before this could happen. The next phase we talked about we would need to identify a national group to create a general core ILP template that could be used as a basis. And then to identify specialty specific groups who could create the specialty specific portions for an ILP.

And then we would also want to partner with Intel who works with the international medical graduates to ensure that we had a good process to include them in the process. For the last phase we talked about how then we would want this group to actually create a core general ILP template and then have the specialty specific groups create their portions. And then identify a consortium that could actually pilot this ILP so we could gather data and have continuous quality improvement in what we created.

Next slide. So thank you. I'm now going to turn it back to our entire panel and Dr. Andrews is going to lead our question and answer session. Thanks to all of our speakers and we have plenty of time for questions. I'm noticing many of my learned colleagues in medical education entering questions so this should be a good discussion. Feel free to enter more questions if you choose to do so. Before we get to the audience question, Dr. Pincavage, since you were the last one to speak I just wanted to follow up.

I know you recently published an article describing some of your own experience using an ILP. I wonder if you have any insights or observations from that that you want to share with our audience. Sure. Yes. We in internal medicine piloted an ILP that we did nationally with volunteer residency programs in internal medicine from the alliance of academic internal medicine. And we found it was very valuable to the programs so they thought it was useful to get a sense of where their incoming interns were coming from, what their strengths and weaknesses were.

Well, not weaknesses, I should say areas for improvement. And they used them to design in some cases the orientation education and early education that they provided to their interns to address areas that were high yield. They also used them as they started coaching them in their first meeting with residency coaches and it was a great place for them to start the conversation. And then we also found, you know, from those of us on the UME side completing them with students who were about to transition that it really helped them sit and take a moment to reflect and think about what they should focus on and even maybe some things that they could do.

Even before they transitioned because they had a little time as we were working on them together. Thanks very much. And those of you who may forget my questions are on another screen so if I appear disengaged I'm only looking over to read them. I return to Dr. Hammoud. Doctor, there's a comment on your introductory remarks. Just making the observation that two years since the publication of the UGRC recommendations is a relatively short timeframe.

And maybe the maybe these shouldn't be considered. Oh boy, my screen just moved. Maybe they shouldn't be considered bold, given how many players there are in the UME to GME transition. Are some of these early signals of positive change heartening or are we really behind in implementing these recommendations? No, absolutely. I completely agree. It does take a lot of time to implement some of these changes. Some of them are very ambitious and they do require a lot of work. I do think that we are seeing in some of these recommendations, really good changes and if you notice, for example, in the one that we had people vote on with the application if we had separate in the in the residency application spaces if we had separated them.

I think some of them would have gotten a lot of better grade because they were all combined together. So there's definitely a lot of spaces where we are seeing changes. And there are some spaces where I think the movement has been a little bit slower. And I do think that part of the challenge is who owns the spaces and who is going to put together the groups. I think that's why sometimes the changes probably a little bit slower than we would like to see them because is it the specialties? Is it the medical schools? Is it the residency programs?

And I think we need to see more of groups that get together kind of what we did, where we got a lot of groups together and follow up on these things and say, how do we actually get more groups together who are who are very motivated to actually make those changes? But absolutely, we're seeing a lot of desire and passion to implement some of these changes. But it is absolutely, I think the entire report was very ambitious and it is some of those spaces are extremely difficult to make changes in.

And we are starting to see some of those things move forward and some of those. But I think that the report itself had some timelines which have not been met. And I think that and maybe those timelines were ambitious, but we have not met our own timelines that were actually outlined in the report itself. Thank you. Dr. Kinnear, I'm turning to you with a question about the coaching relationship. There's a question about the possibility that a learner's personal goals for coaching don't fit with faculty ideas of what expertise and duty look like.

In a coaching relationship, if you have that disconnect, how do you address that? Yeah, great question. Thank you to whoever submitted it. I think I would pause and reflect a moment on what is expertise. So there's a great book. It's from the 80s called Surpassing Ourselves. And I actually can't recall who the author is off the top of my head. But this book challenges the idea that expertise is a thing like a commodity or a destination that we can have. And they actually posit based on empirical evidence that expertise is more of a process that people who we deem as experts, quote unquote, in almost any field, plumbing, driving, being a doctor, being a nurse.

It's actually a process that they have. It's not like the amount of competence they have per se. And so to me, coaching is about that process. It's it probably does matter to some degree about what you're moving toward in that process, but it really is about that metacognitive, reflective process. And how can you teach people the tools and the motivation and the mindset to have a deliberate approach to learning and improvement over time? We focus a lot in education on arrival at competence because that is kind of what we want people to be able to do before they leave medical school or residency or fellowship.

But it really is, I think, the layer beneath that, the metacognitive layer, because what happens when they leave our programs, whether it's going from UME to GME or GME out into practice. So all that to say, there probably is some alignment that needs to happen with maybe what a coach envisions a learner might need and what a learner thinks they need. But I think even more important is just having helping them with the process of reflection and taking a deliberate approach to growth in whatever the thing is they're interested in. Maybe it's on well-being. Maybe it is on professional identity formation. Maybe it's a particular skill or set of skills.

I think any of that is okay because it's more the process that's important because expertise is the process. It's not the destination. Yeah. Ben, you yourself mentioned the fact that we're asking our learners to adopt a growth mindset in an environment in which they're surrounded by high achievement as a goal. Is it the duty of the coach to instill that growth mindset? I mean, how do you develop that in someone who has worked to get to this point through a record of personal achievement rather than necessarily acknowledging gaps in their understanding?

Yeah, another good question. And I don't know that I have the answer for that because if I knew how to help somebody arrive or develop a growth mindset, I think I'd be the education guru of our field and I'm not. But I do think that you can use relationship and reflection to help people even think about what their mindset is. I think in our community, probably everybody who's on this webinar who's viewing it, the idea of growth mindset is so banal that it's almost not even worth mentioning.

But so many of our learners have not even encountered that term or reflected on it. And so I think the power of coaching is having somebody that you trust, a safe space because you have that relationship, and helping them to think about what are the things that motivate you? What happens when you encounter a moment of failure or a moment of success? How do you react? How do you deal with it? And making that a little bit more tangible and invisible to them could be a huge step forward because I think a lot of our learners haven't even thought about it. A lot of our faculty members haven't even thought about this because nobody coached them.

So even if I don't think every single coach should feel the need to instill growth mindset in somebody, I don't know that that's possible. But I think helping them reflect on what their mindset and motivations are can go a long way in getting somebody to even start the journey toward a growth mindset. Thanks, Ben. And I'm sorry to turn the balloons loose on you there. I updated my operating system and it's interpreting my hand gestures in creative ways. Dr. Pincavage, there's a question for you. Is there a way the learner can co-identify or co-create the areas needed for strengthening and residency and contribute to the proposed ILP that can be considered by the program for implementation?

Yeah, so definitely I think so. So, you know, just asking them what are your areas that you need to improve on is very effective and then having someone who knows their performance or reviews it with them, look over those and discuss them with them. So when we did this in the pilot, you know, the learners really were able to identify these areas and they were very broad. So, you know, it wasn't that they were saying the same thing. Obviously, what, you know, level of reflection is different for different learners, but they were able to identify things.

And especially if you give them sort of their competencies in general to reflect upon how prepared they are in certain areas, that can be helpful as well to kind of jump their reflection. So, you know, I do think it is possible and if the learner is part of the discussion and co-creating it and they know it's going to be shared with the program, then it's all transparent and they are comfortable with it. And also the ILP really should be done after they've matched. I think that's extremely important. So it's really not part of the selection process at all.

They've already matched and now they're saying, hey, I am coming to your program. This is what I think I need to work on. And they are the ones being part of sharing that information. And so they really become engaged and are ready to be coached and have, you know, it helps facilitate the growth mindset we're talking about. So as long as they're, you know, it's not part of the selection process and they are co-producing it, you know, that definitely can be done. And there's a related observation or question to that, which just, you know, given your comment about, hey, I'm coming to your program, there's a comment about the merits of understanding the role that the ILP or even coaching plays for students who may stay at the same institution for their residency training.

That we might learn something from that or that it might be easier to evolve that growth mindset in an environment where you're already well known. I don't know if you or Dr. Kinnear have a comment about that. Yeah, I think honestly they can be helpful in going to a new institution or even staying at the same one, you know, because they are so unique to each person. I've seen many of them and made many of them and they're so different to each individual.

So I think even in one's own institution, you assume that they might be one way or another. But you can't really assume that because there are so many different experiences. Our education, especially clinically, you know, we don't know everything each learner seen or experiencing. We might think, oh, well, most of our learners do this, but that student never saw a patient with that. Right. So I think that, you know, really you can learn from it wherever you are in any institution.

Dr. Kinnear, do you have a comment about coaching across the continuum when you remain at the same institution? Do you think that that's there's merit to that? Yeah, I really do. And I think that there's even greater opportunity sometime because, again, coaching at its foundation is about a relationship. I think you have an opportunity when you stay at an institution for even a more longitudinal relationship at times. I think sometimes because coaching programs may not have enough resources to follow with a learner longitudinally, coaching can get a little disjointed at times. But if you're at an institution where you're, let's say, at a medical school and you stay at the same institution for your GM training or you're in GME and you're transitioning to a faculty role or a fellow role, that really represents an opportunity if that coach has the bandwidth to continue the coaching, because we have to remember that when we cross that transition, professional identity formation starts a whole new process because you're forming an identity as a resident, not necessarily as a medical student.

You're learning new skills and competencies. You're facing new well-being challenges. All the things, they're not totally novel, but they take a totally different flavor. And having that kind of continuity relationship could be a really powerful tool in terms of coaching. Here's a really interesting question. An observation from one of the participants, someone who recently graduated from residency, talking about working in an institution where they have a UME to GME handoff.

And one of the biggest barriers we find in information sharing is the learners themselves, wishing to have a fresh start or not wanting information shared because of how it might be interpreted. And in this particular example, they talk about the experience that they've had with a handful of students becoming nervous about creating what he calls a bad first impression, because they haven't perhaps done a lot during the fourth year. They've kind of taken the fourth year off from a clinical standpoint.

And these people have actually made a request not to transmit information from UME to GME. How do we address these fears or psychological barriers that we see in our learners to the growth mindset and to sharing what could be productive information across that transition? And Dr. Pincavage, maybe I'd turn to you first. Yeah, I think that in a lot of these discussions, firstly, also part of an ILP really has to be what are your goals for the first three months or six months?

And when you ask the learners to identify those, they don't say, I want to make a good impression. They say, I really want to improve my clinical efficiency so I can take care of a larger patient volume. I know I'm going to have to do that. So I think many times they do focus on the goals that are more important for the role of a physician in providing patient care. So it's kind of having that discussion to have them think about it in those terms and self-identifying goals more focused on their growth and their improvement rather than performance.

So it helps them reframe the way that they've been thinking from UME for the next steps. And then once you've kind of done that, you can help them think about what they're going to need and what they should work on. And you're reminding them that your program wants to know this so they can help support you. And it's different than, you know, they're not going to be looking at your performance every second. It's really trying to help your professional development.

Thanks. Dr. Kinnear, do you have a comment? Yes, I do. I have many thoughts, but I'll try to keep them brief. So I think this is where we have an opportunity to, especially when you have a trusted relationship like with a coach, be honest and frank with our learners. And the reality is feeding forward of information can create risk, especially in UME where many of our learners are moving, are like constantly thinking about that moment of selection. So they've got to get honors. They've got to get a grade. They've got to perform. The reality is that many of our systems, not all programs, but many of our systems create the conditions where there are real world consequences for our learners if performance is not at a certain level.

The opportunity that the UME to GME transition presents is that for most GME programs, many of those threats are diminished or gone. So it doesn't remove the threat that we all feel when we get critical feedback or we all feel if somebody passes something forward on us that we think is unfavorable. However, I've never heard of a residency program where there's honors. And most of your performance in residency is not as tightly linked to your moment of selection, whether it's for fellowship or a job.

So some of those threats are reduced and that the coaching relationship can be a place where you help try to slowly reframe thinking that has been ingrained in our learners. By the systems in which they've existed and helping them ask one of the one of the strategies I learned from a good friend and somebody I admire in terms of his coaching is Dr. Matt Kelleher. He told me to always use what and how questions. And I don't think he invented that, but he always keeps reminding me of this. And so asking questions to your learner, like what what are the consequences you're most afraid of with somebody feeding forward information to your program director of places where you need to grow?

What would happen if that information came about? What are the and helping them get to the the end point, which is there might be some consequences, but not nearly as drastic of real world consequences as exist in you and me, where everything is around this moment of selection at the end of it. And I think this could be a place where we can really this conversation can be a place where we can start to tip the balance of getting them to realize they are moving out of the world where everything is geared toward performance and selection, because, frankly, nobody's watching that closely anymore. We are not rating you and ranking you in residency. We just want to know, can you take good care of patients? But that is a hard turn to make in our thinking.

And I think we see faculty, we see our faculty peers who have a hard time making that turn because it was so ingrained in us. So this is a hard challenge, but an opportunity. Yeah, thanks. And that's an excellent point about the education environment in GME and how it does differ from the UME environment in some important ways. A little bit of a left turn on this question, kind of a different direction. And again, for both of you, I wonder about your views on the role that generative AI might play in enhancing bandwidth for coaching, perhaps, or in generating or tracking ILPs.

Do you have some thoughts about that? Maybe Amber, I'll turn to you first. Yeah, I mean, I think that they could certainly be used to help summarize performance data for students from UME for them to reflect upon. I think that there definitely could be value in using it for something like that and suggesting, you know, what they in their performance has been observed.

So there's definitely a value, you know, possibility of that. I think also, but there still has to be a lot of self reflection and things done by the learner in the process too. But then certainly summarizing what ILP data is created, you know, making a dashboard or summarizing it for programs or medical schools. I think there's a lot of potential there as well. Thanks. And Dr. Kinnear, I would turn to you. You did, I think, mention some bandwidth issues in instituting coaching programs. Is AI a hindrance or a solution to that?

I hope a solution. So can AI ask reflective questions? Yes. And probably maybe even better than the best trained coaches once we figure it out. Can it improve our bandwidth? 100 percent. The question that I keep getting stuck on and I actually think maybe the answer is yes, is can AI have a relationship? I think so many of us have this adverse reaction to the idea of a relationship with AI, meaning can you have meaningful feelings of connection and trust with AI?

That feels kind of weird and off putting to probably most of us. And I'm not an AI like proponent or in any particular way. I'm, you know, somebody who's very novice in all those things. However, I think those feelings that I have and I'm guessing many people on this webinar share, I don't think will be shared by the generations to come. I think many of us felt weird talking to a little cylinder called Alexa and felt kind of silly. I now have two children who think it's totally normal to talk to Alexa and make her tell her jokes and they don't think twice about it.

You know, I think 20 years ago we would all feel weird if you did two thumbs up and balloons fire. We'd be like, oh, this is crazy. But now it's normal. Like the Overton window of what is normal is moving quickly. And I think that in five, 10, maybe fewer years, learners will come through who will have no problem talking to AI as if it is something they have a relationship with. And if you can do that, you can have a relationship. You can ask questions and you can have even more insight into performance because it can review all their data. And I think this this could be a wonderful tool for coaching.

And I think we should embrace it rather than being afraid of it because we think it's going to replace humanity or something like that. Great. Well, thanks so much. We're approaching the top of the hour. I want to thank all of our speakers for not only their presentations, but for their thoughtful response to all these questions. Furthermore, I want to acknowledge the engagement of George Manekano. I think some of you have seen him contributing to the chat. He was a co-chair of the UGRC committee that generated these recommendations in the first place. And George, pleased to see your endorsement in the chat of our ongoing discussion, the recommendations and our efforts to move things forward.

Thank you all for participating in our webinar today. If I could have the slide, Eric, I'd like to give people the QR for the evaluation. So here's a link to a brief evaluation. If you would use it to give us some feedback on the program, we'll certainly incorporate that into our planning for our future webinar and educational offerings. So once again, thanks to everyone who participated today. Please take a moment to complete the survey. And thanks again to our speakers. Have a good afternoon, everyone.

Good afternoon, everyone. Thank you. Good afternoon, everyone.

Participation Statement: Upon completion of this activity, learners will receive a Participation Certificate.

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