Trainees Are Change Agents: An Introduction to This Year’s Trainee-Authored Letters to the Editor

We [trainees] have inherited a system that breeds complacency and acceptance of health disparities as inevitable. This is a legacy that must end with us. Start today. Start now. The next time someone tells you race is a risk factor, ask “Why?” —Melson et al, “Race as Risk Factor: Always Ask ‘Why?’” 1 The topic of Academic Medicine’s 2021 call for trainee-authored Letters to the Editor was Trainees as Agents of Change in Academic Medicine and the Health Professions. 2 This topic was inspired by the responses to our previous call in 2020, which was Courage, Connection, and COVID-19. In 2020, learners across the health professions shared stories of courage, resilience, and action during a time when they had acted to address the dual community threats of COVID-19 and police brutality. 3 The editors and editorial team of Academic Medicine were particularly moved by the array of letters received in response to the 2021 call, which presented a variety of innovative student-, resident-, and fellow-led initiatives aimed at making strategic advancements in both medical education and the field of health professionals. In light of the response to 2021’s call, and to show appreciation of the importance of effective health advocacy, 4,5 we thought it valuable to offer learners across the health professions another opportunity to report on and discuss actionable ways to create influential change. Early-career authors, including learners in different disciplines and at different stages, are underrepresented in medical education scholarship, yet can be powerful catalysts and partners in cultural change. 6 We hope that this year’s trainee-authored letters will inspire and better enable each of our readers to step up to their role as a change-maker—to build on the letters’ ideas, and to develop new initiatives in collaboration with peers and academic leaders. Learners across the health professions have responded with enthusiasm to the journal’s calls for trainee-authored letters since 2016, when we launched our first call. We received 135 submissions in response to that call. And, since 2019, we have steadily received at least 400 submissions, including 479 submissions in 2021, with 104 (21.7%) of those submissions coming from trainees outside of the United States. The success of this forum is a testament to the importance of inventing places for learners to articulate their views and describe their experiences during their education. By sharing their unique, invaluable, and diverse perspectives, trainees help to advance the field of academic medicine. As was done for the 2020 call, the 479 individual letters received in response to the 2021 call were reviewed initially by multiple editorial board members, assistant and associate editors, and staff editors of the journal; journal reviewers; and/or rising scholars in academic medicine. Our editor-in-chief (L.W.R.) then carefully evaluated the letters to consider them for publication in light of the reviewers’ recommendations. Sixty letters were selected for publication. The submissions were then analyzed to better understand which problems the responding trainees were most interested and committed to addressing, as reflected in the selected letters, and to categorize these problems. The following key themes were identified and will appear in this issue of the journal and in the July and August 2022 issues, respectively: (1) promoting racial justice and equity in medicine, (2) initiatives for building connection, and (3) curricular and institutional change. To explore exactly how trainees are acting as change agents, we examined the letters to identify common aspects of initiatives used to foster change within each of the 3 key themes. Below, we present takeaways, by theme, on the different approaches proposed or enacted by trainees at their institutions and larger communities. Trainees are working to diversify decision-making bodies at all levels within the medical education continuum to create sustainable culture change. For example, fourth-year medical students at the University of Colorado School of Medicine have reformed the selection process of the Alpha Omega Alpha Honor Medical Society to be a holistic review. 7 Pediatrics residents on the equity, diversity, and inclusion committee at the University of Toronto have worked to strengthen a culture of inclusion for residents. 8 Fellows at 2 different medical institutions have called upon medical journals to initiate long-term efforts to make their editorial boards more representative and inclusive and to promote publications that address issues of health inequities and systemic racism. 9 Trainees are implementing strategies to mitigate experiences of discrimination on the wards to promote a welcoming culture for colleagues and patients. For instance, a medical student at the University of Minnesota Medical School has used a framework based on assuming good intentions to effectively address a supervisor who made a transphobic comment about a patient. 10 Trainees at Vanderbilt University School of Medicine have created occasions, such as the annual Thriving on the Wards event held by a group of Asian-identifying medical students, where peers can share their experiences with microaggressions in clinical settings and can brainstorm solutions. 11 Trainees are collaborating with faculty to change medical school curricular content to align with diversity, equity, and inclusion principles. For example, medical students at the Mayo Clinic Alix School of Medicine have encouraged peers to always ask professors “Why?” if race is given as a risk factor for diseases. 1 Medical students and residents have joined forces with faculty at Duke University Health System to successfully remove race as a factor in the Pediatric Urinary Tract Infection Calculator, Fracture Risk Assessment Tool, and the estimated glomerular filtration rate. 12 Medical students at the University of Texas at Austin Dell Medical School have recognized concerning patterns of reductive and stereotypical patient portrayals in case-based learning, and have instilled sustainable measures of diversity, equity, and inclusion alignment through student-led scholarship and longitudinal surveys. 13 Our trainee authors are reaching the public, through popular media, including podcasts and social media, to combat misinformation and bias. For instance, medical students at Albert Einstein College of Medicine and the University of Maryland School of Medicine have founded the External Medicine Podcast to promote change through discussion on topics such as the economic principles behind vaccines. 14 Medical students at 3 institutions have collaborated to launch the Clinical Problem Solvers Podcast Antiracism in Medicine series, equipping listeners with tools to implement antiracist praxis in their clinical careers. 15 Medical students at the Western Michigan University Homer Stryker M.D. School of Medicine have founded the Medical Multimedia Journalists group, which allows students to not only learn how to effectively use social media tools to promote clear and accurate information but also how to strategically reach certain population groups to improve patient care and outcomes. 16 Trainees are supporting their communities through student-led COVID-19 volunteer initiatives. For example, a medical student and her faculty mentor at the University of Michigan Medical School have motivated trainees to teach geriatric patients video telemedicine skills through the Geriatric Education on Telehealth Access initiative. 17 Medical students at 2 institutions have also video chatted with geriatric patients for social support, 18 and pediatrics residents at Cincinnati Children’s Hospital Medical Center have encouraged fellow trainees to help feed local children in poverty by donating part of their Coronavirus Aid, Relief, and Economic Security Act stimulus checks. 19 Our early-career authors are implementing community programs to promote health equity. For instance, interprofessional students at the University of Texas Medical Branch have established the Congestive Heart Failure Comprehensive Care Clinic for heart failure patients who cannot afford outpatient therapy. 20 A fellow at Duke University Medical Center has started HouseCall, which partners residents, senior physicians, community health workers, and lawyers to encourage pediatricians to write letters of support on behalf of patients to their landlords. 21 Trainees are working with academic leaders to ensure the institutional culture represents their diverse voices and interests. For example, medical students at the University of Miami Miller School of Medicine have identified 7 areas for improvement, with action items for their institution—ranging from local police reform to wellness accommodations for systemic trauma. 22 Two student/trainee-led groups (Price of a Dream and Community of Support) have aimed to increase representation of students from low socioeconomic status by partnering with the Association of Faculties of Medicine of Canada. 23 Members of the national Choosing Wisely Students and Trainees Advocating for Resource Stewardship (STARS) program have recognized attending physicians at the University of Texas at Austin Dell Medical School who practice high-value care by giving them student-nominated awards. 24 Two medical students and 1 dental student have worked to expand the Interprofessional Education Student Advisory Committee aimed at increasing communication and collaboration across the health professions schools at the University of Michigan. 25 And 2 PhD scientist students at the Indiana University School of Medicine have united with classmates to implement a peer wellness program using trained coaches to help peers achieve their personal and professional goals. 26 Our trainee authors are collaborating with faculty to reform the medical curriculum. For instance, medical students at the University of California, San Francisco School of Medicine have developed the Planetary Health Report Card to help medical schools integrate climate and health education into the curriculum and to support student-driven climate action. 27 The student committee at Case Western Reserve University School of Medicine has collaborated with the school’s administration to create an elective that teaches students how to develop core curricular materials using research-supported methods. 28 And medical students at the University of Connecticut School of Medicine have recommended 3 actionable steps at their institution to integrate disability inclusion and representation into the medical curriculum. 29 We received far more compelling stories of trainees acting as change agents than the above samples from 60 letters could highlight. After thorough evaluation, only 12% of the submissions were accepted for publication. To show our regard for the great work, thoughtfulness, and efforts of trainee authors whose letters received excellent reviews, we have posted a list of honorable mentions on our website (https://journals.lww.com/academicmedicine/Pages/2021-Honorable-Mentions.aspx). We encouraged those who received honorable mentions to share the link with faculty, mentors, residency program directors, and others. In this issue and the next 2, we invite you to learn more about the tangible, actionable changes that our early-career colleagues have been proposing and making. We hope our readers recognize that trainees have the ability to influence the culture of medicine for the better. By building on this foundational work across the country and the world, we anticipate a more equitable and fulfilling future.

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