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The American Council of Graduate Medical Education is moving from accrediting residency programs every 5 years to a new system for the annual evaluation of trends in measures of performance. In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced the six domains of clinical competency to the profession, 1 and in 2009, it began a multiyear process of restructuring its accreditation system to be based on educational outcomes in these competencies. The result of this effort is the Next Accreditation System (NAS), scheduled for phased implementation beginning in July 2013. The aims of the NAS are threefold: to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century, to accelerate the ACGME's movement toward accreditation on the basis of educational outcomes, and to . . .

From 2000 to 2014, the leading causes of medical resident death in the United States were neoplastic diseases and suicide. To examine whether US medical resident rates of death have changed since 2014 and whether causes of resident death differ by specialty. In this cross-sectional study, residents and fellows who were enrolled in Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs and who died from January 2015 to December 2021 were submitted to the National Death Index to obtain causes of death. These decedents were compared with residents and fellows who died between January 2000 and December 2014. Data were analyzed between July 2024 to March 2025. Death while actively enrolled in an ACGME-accredited residency and fellowship training program. The primary outcome was the difference in rates of death for US residents and fellows between 2 time periods, 2000 to 2014 and 2015 to 2021. Poisson regression modeling was used to calculate incidence rate ratios (IRRs) with 95% CIs for this comparison. Rates were also compared across specialties. Secondary outcomes included comparing trainee decedents with age- and gender-matched peers in the general population and querying differences in causes of death by specialty from 2000 through 2021. Between 2015 and 2021, 370 778 residents and fellows participated in 961 755 person-years of training. In that same period, 161 residents (50 [31.1%] female; median [IQR] age, 31 [29-35] years) died during training. Forty-seven residents (29.2%) died by suicide, 28 (17.4%) by neoplastic diseases, 22 (13.7%) from other medical and surgical diseases, 22 (13.7%) from accidents, and 21 (13.0%) from accidental poisoning. The highest number of resident suicides occurred during the first quarter of the first year. The death rate from neoplastic diseases decreased since 2000 to 2014 (IRR, 0.59; 95% CI, 0.38-0.90). Rates of other causes remained unchanged. Resident death rates from 2000 to 2021, including rates of death by suicide, were lower than age- and gender-matched peers across causes. The highest specialty suicide rate was for pathology (19.76 deaths per 100 000 person-years). The highest death rate from neoplastic diseases was psychiatry (9.67 deaths per 100 000 person-years). The highest death rate from accidental poisoning was anesthesiology (15.46 deaths per 100 000 person-years). In this cross-sectional study comparing rates of US medical resident deaths from 2000 to 2014 with rates observed in 2015 to 2021, the rate of resident deaths from neoplastic diseases decreased, while the rates of death from all other causes remained unchanged. Nevertheless, the number of residents who died by suicide during their very first academic quarter, observed during both study windows, remains concerning. Future efforts to address trainee well-being must focus on the drivers and mitigating factors of distress, particularly during transitions.

To the Editor: In their article on the Next Accreditation System (NAS), Nasca et al. (March 15 issue) 1 claim that it will “accelerate the ACGME's [Accreditation Council for Graduate Medical Education's] movement toward accreditation on the basis of educational outcomes.” They assert that the introduction of the six clinical competencies has been associated with improved outcomes. Few references supporting this contention are cited, and the only verifiable claim is that of improved performance on certifying examinations. As shown in Table 1 in the Supplementary Appendix (available with the full text of this letter at NEJM.org), board-certification pass rates have not improved over . . .

OBJECTIVE: Successful colorectal cancer screening relies in part on physicians ordering a complete diagnostic evaluation of the colon (CDE) with colonoscopy or barium enema plus sigmoidoscopy after a positive screening fecal occult blood test (FOBT). DESIGN: We surveyed primary care physicians about colorectal cancer screening practices, beliefs, and intentions. At least 1 physician responded in 318 of 413 (77%) primary care practices that were affiliated with a managed care organization offering a mailed FOBT program for patients aged ≥50 years. Of these 318 practices, 212 (67%) had 602 FOBT+ patients from August through November 1998. We studied 184 (87%) of these 212 practices with 490 FOBT+ patients after excluding those judged ineligible for a CDE or without demographic data. Three months after notification of the FOBT+ result, physicians were asked on audit forms if they had ordered CDEs for study patients. Patient‐ and physician‐predictors of ordering CDEs were identified using logistic regression. MEASUREMENTS AND MAIN RESULTS: A CDE was ordered for only 69.5% of 490 FOBT+ patients. After adjustment, women were less likely to have had CDE initiated than men (adjusted odds, 0.66; confidence interval, 0.44 to 0.97). Physician survey responses indicating intermediate or high intention to evaluate a FOBT+ patient with a CDE were associated with nearly 2‐fold greater adjusted odds of actually initiating a CDE in this circumstance versus physicians with a low intention. CONCLUSIONS: Primary care physicians often fail to order CDE for FOBT+ patients. A CDE was less likely to be ordered for women and was influenced by physician's beliefs about CDEs.

Background: Changes in the health care system imply that fewer patients will be admitted to hospitals and attending physicians will be devoting more time to clinical activities with less time for student education. Methods: Surveys of third-year students were conducted for 5 consecutive years at Jefferson Medical College at the end of the required 6-week surgical clerkship at the university hospital or at one of the eight affiliates. Results: The numbers of new inpatients and outpatients encountered by students were not significantly related to students’ overall satisfaction. The ratings of teaching rounds and conferences were significant predictors of satisfaction with the clerkship, as were the ratings of residents’ teaching. Conclusions: As medical education shifts to ambulatory settings, didactic teaching such as rounds and conferences should be maintained and efforts to enhance the teaching skills of residents should be encouraged.

Tree planting and management among inhabitants of three of Zimbabwe's Communal Areas (CAs) is a widespread activity and tree products play an important role in the rural cash economy. However, farmers priorities in tree growing, including the provision of income, have not been integrated into CA forestry programmes. Forestry programmes have tended to emphasize the production of Eucalyptus which, while of some interest to rural households, is by no means the tree 'type' of choice for CA residents. Forestry planning needs to shift away from externally perceived 'problems' and 'solutions' to locally determined priorities. Farmers' initiatives in planting and managing trees and the marketing of tree products provide fertile ground for interventions to improve rural livelihoods. Future planning should focus more attention on fruit trees which provide both food and income. However, the promotion of tree varieties must be associated with a clear understanding of the means by which production excess to subsistence needs is disposed of if rural people are to derive the maximum benefits from incorporating trees into their farming systems. Local solutions should also be emphasized in the management of woodland resources. A shift to local resource control coupled with investment in rural development and improved options for people to generate income from woodlands would likely have positive effects on the management of these resources.

The relationship between one's intimacy attitude's towards other human beings and one's intimacy attitude's towards one's concept of God was explored in this study. Intimacy attitudes toward other people were measured by the Intimacy Attitude Scale (IAS) developed by Amidon and Treadwell (1983) and the Control Attitude Scale-Revised (CAS-R) developed by Amidon (1982). Intimacy attitudes toward one's concept of God were measured by the Divine Intimacy Attitude Scale (DIAS) developed by Brigham & Amidon (1987). A major portion of this study concerned the assessment of validity and reliability of the DIAS. The instruments (plus The Spiritual-Well Being Scale, Religious Experience Index) were administered to 408 individuals drawn from subpopulations of undergraduate, graduates, clergy, and others. Major conclusions drawn from this study are: (1) The DIAS appears to have a high degree of validity and reliability. (2) No practically significant correlation was found between measures of intimacy with other humans (IAS, CAS-R) and with measures of closeness to God (DIAS). (3) When looked at demographically there was a tendency for those groups who scored significantly higher than other groups in their category on measures on intimacy with God, to score significantly lower on measures of intimacy with people. This occurred four times on the dimensions of age, race, religious affiliation and subpopulation groups and in each case the group scoring significantly lower in attitudes toward intimacy with God scored significantly higher in attitudes toward intimacy with people; (a) Clergy scored significantly higher on the DIAS than did graduate students and significantly lower than graduate students on measures on intimacy attitudes with other people; (b) Young adults indicated relatively high levels of intimacy with God and relatively low levels of intimacy with other people; (c) African Americans tended to indicate high levels of intimacy with God and low levels of intimacy with people. Caucasian respondents reported opposite results; (d) Jewish respondents reported lower scores on the DIAS than did Protestants or Catholics and much higher scores than either group on measures of intimacy with other people.

Migratory connectivity is the degree to which populations are linked in space and time across the annual cycle. Low connectivity indicates mixing of populations while high connectivity indicates population separation in space or time. High migratory connectivity makes individual populations susceptible to local environmental conditions; therefore, evaluating migratory connectivity continuously across a species range is important for understanding differential population trends and revealing places and times contributing to these differences. The common nighthawk Chordeiles minor is a widespread, declining, long‐distance migratory bird. Variable population trends across the nighthawk breeding range suggest that knowledge of migratory connectivity is needed to direct conservation. We used GPS tags to track 52 individuals from 12 breeding populations. We estimated migratory connectivity as 0.29 (Mantel coefficient: 0 = no connectivity, 1 = full connectivity) between the breeding and wintering grounds. We then estimated migratory connectivity at every latitude (spatial connectivity) or day (temporal connectivity) of migration and smoothed those migratory connectivity estimates to produce continuous migratory connectivity ‘profiles'. Spatial and temporal connectivity were highest during migration through North America (around 0.3–0.6), with values generally around 0 in Central and South America due to mixing of populations along a common migratory route and similar migration timing across populations. We found local peaks in spatial and temporal connectivity during migration associated with crossing the Gulf of Mexico. We used simulations to estimate the probability that our method missed peaks (spatial: 0.12, temporal: 0.18) or detected false peaks (spatial: 0.11, temporal: 0.37) due to data gaps and showed that our approach remains useful even for sparse and/or sporadic location data. Our study presents a generalizable approach to evaluating migratory connectivity across the full annual cycle that can be used to focus migratory bird conservation towards places and times of the annual cycle where populations are more likely to be limited.