Relational accountability in undergraduate medical education: forming physicians for value-based care

Students now graduate into a health care environment increasingly shaped by value-based incentives and accountability structures, yet UME remains optimized for individual clinical performance rather than the interdependent work that modern practice requires. Current approaches have largely focused on integrating health systems science and related competencies through curricular frameworks and redesign efforts. However, preparing students for value-conscious practice requires more than teaching systems, quality, and cost as concepts; it requires attention to how value-related commitments are modeled, reinforced, and practiced in clinical settings. Building on scholarship that frames professionalism as the bedrock of high-value care, this commentary reframes the value-based care-practice gap not solely as a curricular deficit, but as a problem of professional formation in UME. It proposes relational accountability as a core professional capability linking value-based care, professionalism, and systems improvement, defined as shared responsibility for the downstream consequences of care decisions, enacted through relationships that support transparent reasoning, mutual learning, and collective improvement. Drawing on the "living and leading with love" framework, the commentary emphasizes that accountability grounded in trust, mutual respect, and shared responsibility is a practice available to all individuals, regardless of formal authority. It then outlines three evidence-informed design principles for cultivating relational accountability longitudinally across UME: making accountability explicit, observable, and coachable in everyday care; embedding value-based reasoning into routine clinical decision-making; and building agency before authority through structured participation in transdisciplinary improvement work. Finally, the commentary proposes institution-level action with subsequent cross-institutional learning through a national learning collaborative to test, refine, and scale approaches that make relational accountability visible, coachable, and longitudinally practiced. UME must prepare graduates not only to function within complex health systems, but also to exercise agency in improving them.