United States

Background
Imposter Phenomenon (IP) is the experience of self-doubt in one’s own abilities and failure to internalize success despite achievements. Originally described by Suzanne Imes and Pauline Rose Clance as they observed successful women in the 1970s, the term has since expanded to all individuals who minimize their achievements and perceive their abilities as frauds. This is a common phenomenon seen in the healthcare field, particularly among medical students, affecting their academic performance and leading to burnout. While there are various factors that contribute to the development of self-undermining behavior, one proposed factor is Adverse Childhood Experiences (ACE), which refers to the negative childhood experiences that can have a lasting impact on a person later in life. While there is much research conducted on ACE and IP separately, there are few studies that link the two subjects, and no study has focused on the population of medical students.

Methods
We conducted a 30-question survey-based study that included demographic questions and validated questionnaires assessing IP and ACE. The ACE questionnaire was developed by the U.S. Centers for Disease Control and Prevention and Kaiser Permanente and the Clance IP questionnaire was created by Clance. The survey was distributed to first- and second-year medical students at Burrell COM. Based on a total population of 391 students, the ideal sample size was calculated to be 78 participants.

Results
We collected a total of 103 surveys. The demographic data showed that the majority of the respondents were between the ages of 20 and 35, identified as Caucasian, and identified as female. The ACE and IP scores were analyzed using the paired t-test. It showed a p-value of &lt; 0.01 and a correlation coefficient (R) value of 0.221.

Conclusion
There is a statistically significant relationship between higher ACE scores and higher Clance IP scores in first- and second-year medical students at Burrell COM, although the positive correlation is weak. This result suggests that the adverse experiences from childhood may influence the psychological well-being of medical students. However, our research was limited due to the small sample size and the use of a single institutional population, limiting the generalizability. Further research needs to be done to identify additional contributing factors to IP. We hope this study can contribute to identifying the roots of medical student burnout and encourage more support for their mental health throughout medical training.

AMA Research Challenge 2025 

Determining the Correlation Between Adverse Childhood Experiences (ACE) and Imposter Phenomenon (IP) Experienced in Medical Students from Burrell College of Osteopathic Medicine

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AMA Research Challenge 2023

Join the AMA Research Challenge poster symposium and semifinals to explore top research posters, score posters in the semifinals (an AMA member exclusive opportunity) and attend education sessions with experienced physicians to learn tips to advance your research and career. 

Background
Imposter Phenomenon (IP) is the experience of self-doubt in one’s own abilities and failure to internalize success despite achievements. Originally described by Suzanne Imes and Pauline Rose Clance as they observed successful women in the 1970s, the term has since expanded to all individuals who minimize their achievements and perceive their abilities as frauds. This is a common phenomenon seen in the healthcare field, particularly among medical students, affecting their academic performance and leading to burnout. While there are various factors that contribute to the development of self-undermining behavior, one proposed factor is Adverse Childhood Experiences (ACE), which refers to the negative childhood experiences that can have a lasting impact on a person later in life. While there is much research conducted on ACE and IP separately, there are few studies that link the two subjects, and no study has focused on the population of medical students.

Methods
We conducted a 30-question survey-based study that included demographic questions and validated questionnaires assessing IP and ACE. The ACE questionnaire was developed by the U.S. Centers for Disease Control and Prevention and Kaiser Permanente and the Clance IP questionnaire was created by Clance. The survey was distributed to first- and second-year medical students at Burrell COM. Based on a total population of 391 students, the ideal sample size was calculated to be 78 participants.

Results
We collected a total of 103 surveys. The demographic data showed that the majority of the respondents were between the ages of 20 and 35, identified as Caucasian, and identified as female. The ACE and IP scores were analyzed using the paired t-test. It showed a p-value of < 0.01 and a correlation coefficient (R) value of 0.221.

Conclusion
There is a statistically significant relationship between higher ACE scores and higher Clance IP scores in first- and second-year medical students at Burrell COM, although the positive correlation is weak. This result suggests that the adverse experiences from childhood may influence the psychological well-being of medical students. However, our research was limited due to the small sample size and the use of a single institutional population, limiting the generalizability. Further research needs to be done to identify additional contributing factors to IP. We hope this study can contribute to identifying the roots of medical student burnout and encourage more support for their mental health throughout medical training.

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Background: Prostate cancer (PC) growth is driven by androgen receptor (AR) signaling, and AR-targeted therapies extend survival in many patients. However, advanced tumors develop resistance to these therapies via various mechanisms like adopting basal-like or stem cell–like (SCL) transcriptional programs, which are less dependent on AR and linked to aggressive, treatment-resistant disease. As 30-40% of PCs are basal-like, identifying underlying mechanisms in which these PCs become basal or SCL is vital for treating aggressive PCs. CREB5, a transcription factor, has been implicated in the progression of breast, colorectal, and prostate cancers. However, while these studies independently point to CREB5 as a key factor of tumor progression, the underlying transcriptional regulatory role of CREB5 in PC remains elusive.

Methods:
We analyzed RNA-sequencing data from 701 patient tumors (n=208, Stand Up To Cancer; n=493, TCGA) to assess correlations between CREB5 expression, AR activity, and basal and SCL gene signatures. In an AR-positive PC cell line (LNCaP), rapid immunoprecipitation mass spectrometry of endogenous protein (RIME) and chromatin immunoprecipitation (ChIP) assays determined CREB5’s protein interactions and its binding to regulatory DNA elements. Functional impact on tumor progression was evaluated by measuring three-dimensional tumorsphere formation in vitro, and assessing tumor growth in mouse xenografts with CREB5 overexpressed in the LNCaP cell line.

Results:
High CREB5 expression inversely correlated with AR signaling and positively correlated with basal-like and SCL transcriptional programs in both primary and castration-resistant PCs. We found that CREB5 protein interacted with AP-1 factors, which have previously been implicated in stem cell features, therapy resistance, and metastasis. CREB5 also bound to regulatory elements of several AP-1 factors,  suggesting a complex mechanistic role in regulating activity of numerous AP-1 genes. Functionally, cells overexpressing CREB5 formed significantly more tumorspheres and produced larger tumors in vivo, demonstrating its association with enhanced stemness and aggressive growth in PC.

Conclusion:
Altogether, this study indicates that CREB5 enhances PC tumor progression through genes that are associated with SCL transcriptional programs. Therefore, CREB5 may act as a pivotal regulator of differentiation in PC. As CREB5 was associated with AP-1 family members, this may be a mechanism of such tumor progression. Altogether, increased CREB5 may lead to specific mechanisms of therapy response, and future therapeutic strategies may consider antagonizing CREB5 interactions with AP-1 complexes to mitigate tumor progression in deadly PCs.

CREB5 Regulates Stem Cell-like Transcriptional Programs to Boost Tumor Formation in Prostate Cancer

Background: Fertility typically returns after kidney transplantation; however, pregnancy in this population remains high-risk. Although most result in live births, rates of fetal complications including preterm birth, low birth weight, fetal growth restriction (FGR), and cesarean delivery are significantly elevated, especially among individuals of advanced maternal age. Pregnant kidney transplant recipients also experience higher rates of preexisting hypertension and pre-eclampsia compared to the general obstetric population. Furthermore, pregnancy following solid organ transplantation may increase the risk of graft dysfunction or rejection due to immunologic complications. Limited data exists on pregnancy outcomes in this group. This study provides a descriptive statistical analysis of a small cohort of women who became pregnant following kidney transplantation.

Methods: Data were collected from 17 women who became pregnant after renal transplantation (5.9% White, 41.2% Black, 47.1% Hispanic, 5.9% Asian). Participants lived in areas with limited neighborhood resources (mean Area Deprivation Index = 75%, SD = 20.8). The average time from transplant to delivery was 8.2 years. Exploratory descriptive statistics and correlation analyses were performed to examine risk factors and outcomes before and after transplant, as well as pre/peri/post pregnancy, in relation to medical and social determinants of health.

Results: Relevant significant positive correlations were found between Body Mass Index (BMI) at the time of transplant and during the first and second trimesters, and serum creatinine levels measured one month before pregnancy, at conception, and at the end of the first trimester. Additionally, longer duration on dialysis prior to transplant was associated with lower neighborhood resource access.

Conclusions: This exploratory study provides insights into a unique sample of women who pursued pregnancy following renal transplant at a large urban public medical center. Findings of this study provide insights into relevant risk factors and considerations for optimizing pregnancy and graft outcomes in this high-risk population.

 Pregnancy Outcomes in Kidney Transplant Recipients at an Urban Academic Medical Center


Background: Fluoroscopy has become essential in orthopedic surgery, particularly with the rise of minimally invasive surgery (MIS) techniques. Despite its advantages, it raises concerns about radiation exposure to both patients and surgical staff. This study evaluated fluoroscopy time and radiation dose associated with open versus MIS bunion correction, comparing the modified Lapidus procedure (open) and the MIS distal transverse osteotomy. Additionally, we compared these procedures to historical controls of common orthopedic surgeries to understand relative exposure risk. It was hypothesized that MIS procedures would be associated with increased radiation exposure and fluoroscopy time however compared to historically controls, both procedures would be significantly less.

Methods: A retrospective review was conducted for patients who underwent a bunion correction between January 2021 and June 2025 by one of two fellowship-trained foot and ankle surgeons at a single academic institution. A total of 294 patients met inclusion criteria. Of these, 258 patients underwent a MIS distal transverse osteotomy and 36 underwent a modified Lapidus procedure. Fluoroscopy time (minutes) and radiation dose (mGy) were compared between groups. Historical controls utilized were intramedullary tibial nailing and distal radius plating.

Results: A mean fluoroscopy time of 2.13±1.27 (range, 0.06-7.05) minutes and radiation dose of 2.02±1.30 (range, 0.05-7.52) mGy was observed in the MIS distal transverse osteotomy cohort. An average fluoroscopy time of 1.63±1.83 (range, 0.08-7.70) minutes and a radiation dose of 1.31±1.43 (range, 0.07-5.98) mGy was observed in the modified Lapidus cohort. There was no significant difference in fluoroscopy time (p=0.123), but the MIS group demonstrated a higher radiation dose (p=0.007). Compared to other orthopedic procedures, the MIS cohort showed significantly lower radiation doses than intramedullary tibial nailing, which requires an average dose of 137.00±111.00 (range, 41.00-378.00) mGy (p=<0.001) and distal radius plating, which requires an average dose of 17.00±10.00 (range, 3.30-26.00) mGy (p=0.007). 

Conclusion: MIS distal transverse osteotomies result in higher radiation exposure than open modified Lapidus procedures, though both remain substantially below levels seen in other orthopedic surgeries. Despite MIS distal transverse osteotomies generating an average radiation dose of 2.02 mGy per case, surgeons receive only 0.50% of the dose; thus, nearly 1,980 procedures would be required to exceed the 20.00 mGy annual occupational limit. Over a 30 year career, performing 50 such cases annually would increase lifetime cancer risk by 0.075%. These findings suggest that concerns about radiation exposure should not deter providers from performing MIS distal transverse osteotomies for bunion correction.

Radiation Exposure and Safety in Minimally Invasive Foot and Ankle Surgery: A Comparative Analysis Between Minimally Invasive and Open Bunion Correction

Optimizing the Value of Knee Injections: Comparative Analysis of Hyaluronic Acid and Corticosteroids 

Background:
In the U.S., approximately half the total population will develop knee osteoarthritis. Among them, nearly 50% of patients pursue intra-articular injections prior to total knee arthroplasty. Despite widespread use, the comparative value between corticosteroids (CS) and high molecular weight hyaluronic acid (HMW-HA) injections remains uncertain. This study evaluates each through cost analysis and prospective patient-reported outcomes. We hypothesize that CS injections will demonstrate superior value compared to HMW-HA. 

Methods:
Patients receiving CS or HMW-HA injections were recruited. Time-driven activity-based costing categorized total costs into direct variable labor (DVL), direct variable supply (DVS), direct fixed (DF), and indirect. Patient-reported outcomes were assessed using PROMIS Pain Interference (PROMIS-PI), PROMIS Physical Function (PROMIS-PF), and KOOS-JR at baseline, 3, and 6 months. Score changes from baseline to 3 months were multiplied by average duration of benefit to estimate quality-adjusted life years (QALYPI, QALYPF, QALYK). Total cost was divided by each QALY to determine Value. Lower cost per QALY indicates greater cost-effectiveness. 



Results:
Twelve patients received CS, 11 received HMW-HA. Average total cost was significantly lower for CS ($124.58) than HMW-HA ($604.19, p < 0.001). DVL costs were similar (CS: $13.41; HMW-HA: $13.06, p = 0.84). DVS costs differed significantly (CS: $10.61; HMW-HA: $367.14, p < 0.001). DF (CS: $33.52; HMW-HA: $74.66, p = 0.09) and indirect costs (CS: $67.04; HMW-HA: $149.32, p = 0.009) were higher for HMW-HA. 

QALYs were not significantly different: QALYPI (CS: 0.60; HMW-HA: 0.59), QALYPF (CS: 1; HMW-HA: 0.36), QALYK (CS: 2.59; HMW-HA: 1.77). 

Value measures favored CS: 
ValuePI: CS $206.21 vs. HMW-HA $1,022.47 
ValuePF: CS $124.58 vs. HMW-HA $1,661.51 
ValueKOOS: CS $48.09 vs. HMW-HA $348.46 

Conclusion:
CS injections were significantly less costly, mainly due to lower supply costs, and showed similar clinical benefit to HMW-HA at 3 months. CS demonstrated greater cost-effectiveness across all PROMs. 

A limitation is short follow-up, though both injections typically provide around 3 months of benefit. Some evidence suggests effects may last longer. Continued follow-up may be valuable. 

These findings highlight the importance of evaluating both outcomes and cost to determine treatment value.

Optimizing the Value of Knee Injections: Comparative Analysis of Hyaluronic Acid and Corticosteroids​

Background: 
Placenta Accreta Spectrum (PAS) is a pregnancy complication in which the placenta abnormally adheres to the uterine wall. Complications include damage to nearby structures, infant prematurity, and potentially life-threatening maternal hemorrhage during delivery, often necessitating hysterectomy. Thus, careful considerations should be given to adequate planning to minimize morbidity and mortality. This case provides an example of a high-risk obstetric presentation with a focus on anesthetic strategies utilized for intraoperative coordination within a multidisciplinary team to achieve a favorable maternal and fetal outcome. 

Case Presentation:
32-year-old G4P2012 at 32w4d with a medical history of gestational diabetes requiring insulin, two prior cesarean deliveries, obesity, and suspected chronic hypertension presents for a scheduled cesarean section hysterectomy for PAS with placenta previa in the third trimester. Prior imaging showed the findings above in addition to loss of uterovesical interface suggesting invasion. The patient was subsequently admitted to the antepartum unit at 24w3d for inpatient management in preparation for planned surgery.

Discussion: 
Several anesthesia-specific considerations including airway access, hemodynamic stability, and pain control were essential to the effective pre-, intra- and post-operative management of this patient. Moreover, coordination within the various procedural segments remained an integral component to optimizing efficiency and minimizing adverse risks. 

In approaching airway management, the patient was assessed pre-operatively utilizing the Mallampati score. She was determined to be class III, and thus video laryngoscopy was deemed the preferred technique for endotracheal intubation. Furthermore, due to the high risk of bleeding, her current hemodynamic state was evaluated and blood products were acquired in preparation. Prior to surgery, most recent hemoglobin and platelet count were 13.0 and 220, respectively. Two 18-gauge IVs were placed for access. Patient monitoring was performed using blood pressure and continuous pulse oximetry.

In regard to analgesic therapy, the patient was given a combination spinal/ epidural for primary intraoperative anesthetic and post-operative pain management. Spinal anesthesia was induced prior to the initial interventions of urology and interventional radiology. Following which, the epidural was dosed and upon being deemed adequate, general anesthesia was inducted; subsequently allowing for hysterotomy, fetal delivery, and hysterectomy with bilateral salpingectomy performed by the obstetric team. The patient remained hemodynamically stable throughout the remaining surgical interventions, and post-operatively recovered from anesthesia with adequate pain management. 

Thus, this case underscores the importance of anesthetic considerations within the coordination of multidisciplinary approaches, highlighting anesthesia’s role in optimizing the patient pre-, intra-, and post-operatively for complex cases to reduce adverse events.


Approaching Placenta Accreta Spectrum: An Anesthesia-Centered Perspective Within a Multidisciplinary Framework

Background
Abdominal aortic aneurysms (AAA) have a global prevalence of about 1% and account for 150,000-200,000 deaths annually. When identified, a patient may undergo endovascular aortic repair (EVAR) to prevent further aneurysmal dilation. These grafts may present with an endoleak requiring an additional EVAR. Grafts can obstruct blood flow to branching vessels comprising supply to structures including the spinal cord. To prevent spinal cord ischemia (SCI) in high-risk cases, spinal drains (SD) are placed. SD placement can present with its own complications that warrant further research as highlighted in the case presented.
Case Presentation
An 85-year-old man with a complicated medical history associated with AAA management presented to the emergency department (ED) with persistent back pain radiating to the left lateral thigh and left leg weakness. Eleven days prior, apixaban use was stopped for SD placement after a type 1 endoleak was identified. The SD was unsuccessful. MRI showed a subdural hematoma spanning T12 to the left lateral aspect of L1. Excavation without further injury was deemed difficult due to proximity to the cauda equina and thrombus adhesion leading to support for watchful waiting. A few days later, imaging showed aneurysmal enlargement and intervention became imperative. Upon second attempt at SD placement, pink-tinged aspirate was evident, so the drain was removed. A third attempt at SD placement was made. Due to lack of CSF return and new onset lower extremity weakness, the drain was removed. A fenestrated EVAR was performed. Post-operative, the patient was diagnosed with incomplete paraplegia and was evaluated for rehabilitation.
Discussion
EVAR is the recommended treatment for a type 1 endoleak, but it has a risk of SCI. A 2018 study demonstrated the risk of paralysis during EVAR drops from 20% to 2.3% after a SD is placed. The risk of subdural hematoma with SD placement may have increased due to prior use of the anticoagulant Apixaban (an associated side effect) combined with repeated spinal procedures. Although the patient was not taking Apixaban at the time of drain placement, further research is required to determine if the drug may have an effect after stopping its use. Furthermore, the risk of paralysis associated with SD placement increases from 3% at first placement to 12% at second placement. This case demonstrates that risks for SD complications in patients undergoing EVAR should be further studied.

Complication Risk Related to Spinal Drain Placement for Endovascular Aortic Repair

Background 
Lennox-Gastaut syndrome (LGS) is a rare neurologic disorder characterized by drug-resistant seizures, intellectual disability, and motor dysfunction, typically presenting between ages three and five. This case highlights a unique presentation of early onset type 2 diabetes mellitus (T2DM) in a medically complex 18-year-old male patient with LGS - a combination that, to our knowledge, has sparsely been reported. 

Case Presentation 
Like many patients with LGS, this patient suffered extensive seizures requiring multiple seizure medications: clobazam, diazepam, levetiracetam, and methsuximide. His history also included neuromuscular disease, cerebral palsy, microcephaly, global delay, and ventricular arrhythmias managed with atenolol. His biological mother had schizophrenia, and he was adopted shortly after birth, with no other family medical history available. 

At age 10, the patient was noted to have acanthosis nigricans and a five pound weight loss over the past year while on a regular diet. Progressive dysphagia due to sensorimotor deficits developed over the next two years, requiring a pureed and thin-liquid diet. Some of his seizures, described as subtle head drops, often occurred during meals. Between the ages of 12 and 13, he was placed in a special care facility with monitored feeding. 

At age 16, the patient acutely developed decreased responsiveness for 24 hours, without fever, emesis, diarrhea, rash, or respiratory distress. Laboratory workup revealed ketosis (beta hydroxybutyrate=9.1), acidosis (pH=7.30), hemoglobin A1c 8.2%, glucose=840 mg/dL, bicarbonate=16, and H/H=18.7/58, with normal procalcitonin and lactate. Blood glucose was promptly managed with daily Lantus and Humalog corrections every four hours, while an endocrinology consultation and diabetes antibody workup suggested a T2DM presentation. 

Discussion 
Diabetes mellitus is not typically associated with LGS, however, several risk factors are present in this case. The association of seizures with feeding difficulties and metabolic stress have reciprocal effects on brain function, and furthermore, can complicate glycemic control in a chronically ill patient with LGS. Medications such as benzodiazepines and levetiracetam can also affect glycemic control, though their effects on the LGS population are not well understood. Finally, this patient’s LGS was attributed to a RHOBTB2 gene mutation, which has links to glucose metabolism as well. Nevertheless, while insulin resistance is often associated with obesity and metabolic syndrome, this patient's presentation was preceded by a healthy BMI, 
progressive dysphagia, and a regimented diet. These factors cumulatively emphasize the need for heightened vigilance in screening for metabolic complications in this vulnerable population, even in the absence of typical risk factors.


A Surprising Case of Type 2 Diabetes Mellitus in a Diet Restricted Lennox Gastaut Adolescent

BACKGROUND
Pulmonary mucormycosis is a rare but life-threatening fungal lung infection, most commonly seen in immunocompromised patients. The causative fungi belong to the order Mucorales, with Rhizopus species being most common. Growing on decaying food, soil, and animal excrement, patients usually become infected via spore inhalation. Risk factors include diabetes mellitus (particularly diabetic ketoacidosis), hematologic malignancy, and solid organ or stem cell transplant.

CASE PRESENTATION
A 47-year-old female with newly diagnosed, unmedicated Type 2 diabetes and a recent DKA hospitalization presented with a 3-month cough and 5 days of worsening hemoptysis. She denied systemic or respiratory symptoms, smoking, or drug use. She had recently emigrated from El Salvador and had a prior admission for community-acquired pneumonia revealing a cavitary lesion concerning for prior Tuberculosis (TB), though Quantiferon Gold was negative. Interval imaging was planned to rule out malignancy.
On this admission, CT chest showed increased left hilar soft tissue encasing a dilated left pulmonary artery (PA), concerning for pseudoaneurysm (PSA). Bronchoscopy revealed bleeding in the left upper lobe; endobronchial ultrasound showed invasion and thinning of the PA wall. Due to high rupture risk, Interventional radiology was consulted, but embolization was contraindicated due to lesion proximity. Biopsy was deferred given risk, and after multidisciplinary discussion, the patient underwent a left thoracotomy and pneumonectomy.
Post-operative recovery was uneventful. Infectious disease initiated RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) therapy due to TB concern. However, final pathology revealed pulmonary mucormycosis. RIPE was discontinued, and she was transitioned to AmBisome and Cresemba for 12 weeks, with follow-up imaging planned.

DISCUSSION
Pulmonary mucormycosis is a rare infection with a high mortality rate. Estimated burden in the U.S. is 3.0 cases per million people annually, with mortality rates greater than 50%. A high index of suspicion is essential, particularly in patients with non-resolving pneumonia despite antibiotic therapy, presence of cavitary lesions on imaging, diabetes mellitus, or history of solid organ/stem cell transplant. In diabetes, tuberculosis is a more common consideration which may delay diagnosis. Diagnosis typically involves bronchoalveolar lavage and histopathological sampling. The gold standard for diagnosis is via endobronchial biopsy showing Mucorales hyphae with tissue invasion. Imaging may show upper lobe predominance on CXR and reverse halo sign on CT. Management requires aggressive treatment, often combining antifungal therapy and surgery. FDA-approved treatments include liposomal Amphotericin B and Isavuconazole with Posaconazole as an alternative. Surgical options, such as lesion excision or pneumonectomy, may be necessary in advanced cases.

The Great Mimicker: A Case of Pulmonary Mucormycosis Leading to Left Pulmonary Artery Pseudoaneurysm and Subsequent Pneumonectomy in a Diabetic Middle-Aged Female from El Salvador with Tuberculosis Symptoms

Background
The July Effect refers to the proposed phenomenon in which the quality and safety of patient care in teaching hospitals may decline in July, coinciding with the annual turnover and advancement of medical trainees. Several studies have investigated this effect, with some reporting a transient increase in adverse events, while others have found minimal or no impact. Acute decompensated heart failure (ADHF) represents a high-risk condition where quality of care may be particularly sensitive to such transitions.

Methods
We analyzed the 2018–2022 National Inpatient Sample (NIS) to identify adults hospitalized with ADHF. We compared July and May admissions to isolate seasonal effects unrelated to the trainee transition. Hospitals were classified as teaching or non-teaching. We performed survey-weighted difference-in-differences (DiD) analyses to evaluate the impact of July admissions on mortality, length of stay (LOS), and total hospital charges across hospital types. Models were adjusted for demographics, socioeconomic indicators, Charlson comorbidity index, hospital region, bed size, and payer.

Results
The adjusted DiD analysis demonstrated a statistically significant interaction indicating that the relative increase in mortality associated with July admissions was smaller in teaching hospitals than in non-teaching hospitals (adjusted odds ratio 0.95, 95% confidence interval 0.92–0.99, p=0.009). However, within teaching hospitals, the adjusted mortality rate was slightly higher in July (1.40%) compared to May (1.35%). In non-teaching hospitals, the adjusted mortality rate increased from 1.12% in May to 1.22% in July, although this change was not significant in the interaction analysis.

For LOS and total hospital charges, the adjusted DiD interaction terms were not significant (p=0.197 and p=0.292, respectively), indicating no appreciable change between May and July in teaching hospitals relative to non-teaching hospitals. Each subgroup analyzed represented more than two million weighted hospitalizations, ensuring robust estimates.

Conclusion
Although adjusted mortality rates were slightly higher in July versus May within teaching hospitals, the difference-in-differences analysis indicated that the relative increase in mortality associated with July admissions was smaller in teaching hospitals than in non-teaching hospitals. These findings suggest no evidence of a detrimental July effect for ADHF, and instead point to stable outcomes during the trainee transition period. Length of stay and hospital charges were unaffected, underscoring that modern teaching hospitals may maintain consistent care quality for high-risk conditions like ADHF despite resident turnover.

Impact of July Effect on Outcomes in Acute Decompensated Heart Failure: A Difference-in-Differences Analysis Using the National Inpatient Sample

Background:
Physician involvement in advocacy and health policy is crucial for advancing patient care, population health, and increased access to equitable care. Medical students and trainees often do not receive formal training or accessible resources to learn about the legislative process and to take action. To address this gap, we have created a guide to help medical students and other trainees learn about the legislative process and how to testify at the Rhode Island State House.

Program Description: 
The Rhode Island Health Advocacy and Testimony Guide is a student-made resource created to provide medical students and other medical trainees with a basic understanding of the Rhode Island legislative process. It contains information on how to engage with the State House through written and verbal testimony and how to follow the outcomes of the bills that trainees testify on through time.

Discussion: 
The guide strives to increase student engagement with testimony at the Rhode Island State House, to increase student knowledge about the process of tracking bills as they develop through the Rhode Island legislature, as well as to increase student and trainee confidence with providing written and verbal testimony. This resource will hopefully increase the amount of trainees that testify at the State House as well as to increase discussion of bills being heard and the implications that those bills have on patient care.

Future Directions: 
Future directions of this project include evaluating student confidence in providing testimony, integrating more bill advocacy education into the medical student curriculum, as well as adapting the resource for other medical schools to be able to use as a model.

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