United States

Context: Some racial and ethnic groups are underrepresented in the medical field because they face unique barriers to admission to medical school. One admission requirement that can present a barrier for applicants is the physician letter of recommendation (PLOR). Undergraduate students report confusion with the application process and lack of mentorship to be one of their biggest challenges to becoming a doctor. It is especially challenging to those who already have limited access to practicing physicians. Therefore, we hypothesize that in the presence of a PLOR, the diversity of students who apply and matriculate into medical school will be decreased. 
Objective: To determine if a relationship exists between a PLOR requirement for the medical school application and proportion of underrepresented in medicine students applying and matriculating to that school.
Methods: A descriptive study was conducted using data published by the American Association of Colleges of Osteopathic Medicine Application Services (AACOMAS) on the race and ethnicity of applicants and matriculants to osteopathic medical schools during the years 2009-2019. In total, 35 osteopathic schools with 44 campuses were included in the study. Schools were grouped based on whether they required a PLOR. For each group of schools, descriptive statistics were performed for the following variables: number of total applicants, class size, application rate per ethnicity, matriculation rate per ethnicity, number of applicants per ethnicity, number of matriculants per ethnicity, and percentage of student body per ethnicity. The Wilcoxon rank-sum test was used to detect differences between the two groups. Statistical significance was assessed at the α = 0.05 level.
Results: Schools that required a PLOR showed decreases in both class size and number of applicants across all races and ethnicities. Black students showed the greatest difference between groups and were the only ethnicity to show significant reductions across all outcomes in the presence of a PLOR. On average, schools that required a PLOR have 37.3% (185 vs 295; p&lt;.0001) less Black applicants and 51.2% (4 vs 8.2; p&lt;.0001) less Black matriculants. 
Conclusions: This study strongly suggests a relationship between PLOR’s and decreasing racial and ethnic diversity in medical school matriculants, specifically the Black applicants. Based on this result, it is recommended that the requirement of a PLOR be reconsidered for osteopathic medical schools.


2022 AMA Research Challenge

The Impact of the Phyician Letter of Recommendation on Medical School Admission Demographics

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#### Event Details
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Ricardo Correa, MD, EdD
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Stuart M. Greenstein, MD
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Stephanie Strohbeen, MD
 
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

### Sponsor
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Registration Is Required

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Context: Some racial and ethnic groups are underrepresented in the medical field because they face unique barriers to admission to medical school. One admission requirement that can present a barrier for applicants is the physician letter of recommendation (PLOR). Undergraduate students report confusion with the application process and lack of mentorship to be one of their biggest challenges to becoming a doctor. It is especially challenging to those who already have limited access to practicing physicians. Therefore, we hypothesize that in the presence of a PLOR, the diversity of students who apply and matriculate into medical school will be decreased. 
Objective: To determine if a relationship exists between a PLOR requirement for the medical school application and proportion of underrepresented in medicine students applying and matriculating to that school.
Methods: A descriptive study was conducted using data published by the American Association of Colleges of Osteopathic Medicine Application Services (AACOMAS) on the race and ethnicity of applicants and matriculants to osteopathic medical schools during the years 2009-2019. In total, 35 osteopathic schools with 44 campuses were included in the study. Schools were grouped based on whether they required a PLOR. For each group of schools, descriptive statistics were performed for the following variables: number of total applicants, class size, application rate per ethnicity, matriculation rate per ethnicity, number of applicants per ethnicity, number of matriculants per ethnicity, and percentage of student body per ethnicity. The Wilcoxon rank-sum test was used to detect differences between the two groups. Statistical significance was assessed at the α = 0.05 level.
Results: Schools that required a PLOR showed decreases in both class size and number of applicants across all races and ethnicities. Black students showed the greatest difference between groups and were the only ethnicity to show significant reductions across all outcomes in the presence of a PLOR. On average, schools that required a PLOR have 37.3% (185 vs 295; p<.0001) less Black applicants and 51.2% (4 vs 8.2; p<.0001) less Black matriculants. 
Conclusions: This study strongly suggests a relationship between PLOR’s and decreasing racial and ethnic diversity in medical school matriculants, specifically the Black applicants. Based on this result, it is recommended that the requirement of a PLOR be reconsidered for osteopathic medical schools.

poster

Background
Asylum seekers face significant and unique healthcare challenges, requiring healthcare practitioners specifically trained in caring for this patient population. However, there is limited understanding of medical students’ interest in and future ability to care for the population of asylum seekers in the United States. We aim to better understand U.S. medical students’ interest, experience, and knowledge in providing care for asylum seekers to inspire change in the ways in which medical schools introduce asylum seeker care to learners.

Methods
A 23-question survey was administered to U.S. medical students at four institutions with asylum programs affiliated with Physicians for Human Rights (PHR) from June 2020 to March 2021, querying various aspects of providing care to asylum seekers. 

Results
Of the approximately 2846 students who received the survey, 436 students (15%) completed it in its entirety. Most respondents desired training about caring for asylum seekers (91%). Over half (52%) rated their knowledge of asylum issues overall as “poor” or “none," and 73% thought their medical school's curriculum on asylum seeker health needed improvement.

Conclusion
This study demonstrated that medical students at schools with affiliated asylum clinics desire to care for asylum patients but feel unprepared to do so, highlighting an unmet need for formal asylum education in U.S. medical schools.

U.S. Medical Student Knowledge and Interest in Asylum Seeker Medical Care

Abstract Title: Urban Myths and Healthcare Disparities for Cardiovascular Care in Black Americans 

Background: Racially based cardiovascular care guidelines in the black population have been pervasive throughout clinical medicine and medical education. These guidelines have largely been based on several unproven recommendations indicating that black individuals have a genetic propensity for the development of hypertension due to chronic stress faced during the Atlantic Slave Trade. This research project aims to dispel antiquated theories regarding race and instead shed light on the importance of assessing social determinants of health (SDOH) and structural/political determinants that affect patient’s disease and outcomes. This education and awareness should begin early on in a physician’s training and continue throughout their career. 

Methods: A literature search was performed utilizing PubMed and Google Scholar with key phrases such as: “slavery hypothesis”, “cardiovascular disease in black individuals”, “salt retention in black individuals”, “eGFR in black individuals”, “hypertension racial guidelines”. There was no time frame that was exempt from the initial literature search. Exclusion criteria included exempting studies not performed within the United States. A possible limitation to this investigation was that specific studies were included such as the Jackson Heart Study, Evans County Cardiovascular and Cerebrovascular Study, and Charleston Heart Study rather than an extensive list of all historic studies. 

Results: The literature review revealed popularity in slavery hypotheses and natural selection theories regarding the significantly higher levels of cardiovascular disease in black individuals, especially in earlier studies conducted. There was a change in rhetoric from the initial studies completed between the 1960s and 1990s, with recent focus placed on socioeconomic status and lifetime discrimination. Other recent studies increased focus on comorbid risk while evaluating for etiologies for cardiovascular health in black americans. Recent findings have demonstrated that hypertension care in black patients should focus on racial disparities, discrimination, and societal inequities rather than innate genetic predispositions. 

Conclusion: It is critical to integrate SDOH, structural and political issues along with scientific research surrounding cardiovascular health in the black population. There is a significant need for early awareness in medical school and residency training to mitigate disparities in the diagnosis and treatment of cardiovascular diseases within this population. 





Urban Myths and Healthcare Disparities for Cardiovascular Care in Black Americans

Wellness, Diversity and Inclusion Among Internal Medicine Residency Programs

Development of an Innovative Quality Improvement Curriculum for Residents and Medical Students in Anesthesia

ACLS instructor certification training as effective preparation for clinical practice

Background: The United States leads the world in incarceration, yet medical students and resident physicians rarely undergo formal training in providing care of the incarcerated patient. 
Methods: A virtual curriculum addressing issues of patient confidentiality, consent, and transitions of care was delivered in the fall of 2021. An interdisciplinary team of clinicians, a formerly incarcerated person, hospital administrators and lawyers, the local police department, and the local jail system created a didactic featuring case vignettes and a panel of a correctional medicine physician and a formerly incarcerated person. In small groups, residents discussed common areas of confusion, such as navigating the presence of an accompanying officer, patient shackling, obtaining the appropriate consent for the treatment of minors in custody, and ensuring patients will receive medications when discharged to a correctional facility. The panel featured a formerly incarcerated person who shared her experiences of receiving healthcare in the jail and prison system, including being pregnant and delivering while being incarcerated. The correctional medicine physician discussed the background of the American criminal justice system, strategies for providing patient-centered care for incarcerated patients, and potential avenues of advocacy and research. 
Results: Post-didactic surveys showed that the curriculum addressed gaps of knowledge regarding the care of the incarcerated patient, such as the structure of the American criminal justice system and the relevance of patient confidentiality laws. Furthermore, qualitative feedback analysis showed resident appreciation for hearing firsthand experiences of incarceration and health, as well as the discussion about the purpose of carceral institutions. 
Conclusion: In a time of increased attention to social inequity, residents should receive explicit training regarding the care of incarcerated patients. Medical schools and residency programs should identify opportunities to provide instruction regarding equitable care of the incarcerated patient. Educational content should also include the role physicians can play in advocating for the health and wellness of patients, including those who are incarcerated.

But What About the Cuffs? A Novel Didactic About the Care of the Incarcerated Patient

Background: During the COVID-19 pandemic, we identified a gap in adequate discharge counseling for COVID-19 patients in the Emergency Department. This was due to high patient volumes and lack of patient education regarding a novel disease. Medical students were also restricted from the clinical area due to safety concerns, compromising their clinical experience. We piloted a novel program in which medical students served as virtual discharge counselors for COVID-19 patients via teleconference. We aimed to demonstrate an impact on patient care via examining the patient bounce back rate as well as assessing medical student education and experience. 

Methods: This program was piloted in a tertiary care Emergency Department. Medical student volunteers served as virtual discharge counselors. Students were trained in discharge counseling with a standardized protocol and a discharge script. Eligible patients for virtual discharge counseling were 18 years old or greater with a diagnosis of confirmed or suspected COVID-19 and no impediment precluding them from participating in a telemedicine encounter. Counseling was provided via secure teleconference in the patient’s preferred language. Counseling included diagnosis, supportive care with medication dosing, quarantine instructions, return precautions, follow up, and time to ask questions. Duration of counseling was recorded and medical students were anonymously surveyed regarding their experience. 

Results: Over an 18-week period, 45 patients were counseled for a median of 20 minutes. The 72-hour ED revisit rate was 0%, versus 4.2% in similarly-matched, not counseled COVID-19 patients. 90% of medical students believed this project increased their confidence when speaking with patients while 80% indicated this was their first telemedicine experience.

Conclusion: Our pilot discharge program provided patients with an extensive discharge counseling experience that would not otherwise be possible in an urban ED setting and demonstrated benefit to patient care. Medical students received a safe clinical experience that improved their communication skills. 


Piloting a Novel Medical Student Virtual Discharge Counseling Process in the Time of COVID

Value-added medical education refers to the experiential learning of medical students to become competent clinicians. We propose applying it for training medical educators: value-added medical educator education (VAMEE). VAMEE is based on the principle of immersive learning for medical students to cultivate skills for teaching, participating in institutional-service-activities, and forming scholarly approaches for curricula development, assessment, and evaluation. Medical students can have value-added roles as student educators under faculty guidance. We present a primary-care clerkship’s student-developed/facilitated cultural humility session, made pre-COVID19 in response to our diverse patient population and LCME requirements, as an example of VAMEE. 

Student educators developed a virtual version of the session: a case-based approach with role-play in breakout rooms. Adaptations were made in response to time constraints, more engaging methods for remote use, and students’/educators’ feedback, under faculty supervision. Session participants were asked to complete pre-/post-surveys, linked through an anonymous identifier, on their confidence in addressing culturally-informed patient encounters, perceived usefulness of the session, and feedback. 

From 01/2021 to 02/2022, there were 161 pre-survey and 124 post-survey responses. Removing duplicates/incompletes yielded 99 paired-responses. Pre-session ratings were 2.7,2.9,and 2.5(scale:0-4) on students' confidence in understanding what “cultural humility” means, understanding cultural humility in primary-care, and approaching patients in a culturally-appropriate way, respectively. Post-session, averages increased to 3.2,3.4,and 3.1. A Wilcoxon-SR test was used to assess significance (mean rank=28.68,Z=-5.3,p<0.001; mean rank=29.17,Z=-5.3,p<0.001; mean rank=28.19, Z=-5.5,p<0.001, respectively). On whether students had learned something useful, responses averaged 4.8(scale:0-6). 

The adaptive potential and benefits of VAMEE were apparent when medical students enhanced faculty’s ability to quickly transform curricula with the pandemic. Results show that not only students benefit by learning from peers but also student educators who gain skills: developing/evaluating curriculum, leading small groups, and giving feedback, through this student-driven reiterative process. Further challenges in curricula are expected with the pass/fail change of Step 1 and the diverse learning needs of current student cohorts. Student educators can work with faculty to innovate educational approaches to transform physician training. Future directions include evaluating long-term impact of the session and surveying student facilitators on the effectiveness of VAMEE in developing their medical educator skills.

VAMEE: Engaging Future Medical Educators to Transform Medical Education Today 

Introduction: 
There are multiple factors that can impact a student’s success in a surgical clerkship, including preclinical curriculum and grades, previously completed clerkships, clerkship sequence and schedule, length of clerkship, work-study balance, and quality of education during the clerkship. These factors make it difficult for medical educators to assess the effectiveness of their preclinical and clinical curricula. This is the first systematic review to date that has analyzed the factors that negatively or positively influence NBME Surgery Subject Exam scores. 


Methods: 
Computer systematic literature searches of the Embase and Pubmed databases were performed. The studies included in this systematic review were papers testing variables that affect NBME subject exam performance of medical students in their third-year surgical clerkships.


Results: 
The literature search resulted in 2,823 articles, of which 17 were selected for analysis. The studies included in this review were grouped into three categories based on variables assessed: preclinical factors, third-year clerkship scheduling or structure, and surgical clerkship educational methods.
Analysis shows that the quality of medical students’ preclinical education plays a strong factor, as USMLE Step 1 scores and second-year NBME scores have a strong positive correlation with exam scores, while shortened preclinical curricula negatively impact third-year NBME exam scores. While the length of the surgery clerkship has varied significance based on multiple studies, the sequence of clerkships showed a consistent correlation with third-year NBME exam scores. Taking medicine clerkship prior to the surgery clerkship showed significant improvement in third-year NBME exam scores across multiple studies. The quality of clinical education received at clerkships is also very important; multiple studies of different educational models have shown that increased student engagement through presentations, small-group case-based learning, and direct resident interaction resulted in increased test scores. Additionally, the student-perceived educational quality along with preceptor-perceived clinical competency via clerkship evaluations and OSCE are positively correlated with NBME subject exam scores.


Conclusion: 
This systematic review looked at multiple factors that influence student success of the NBME Surgery Subject Examination and should be a useful tool for medical educators and students looking to increase NBME Surgery Subject Examination grades at their institution.


Factors Influencing NBME Surgical Shelf Exam Scores: A Systematic Review

Background
Pre-clinical medical students at our institution are trained in sterile technique by volunteer scrub technicians in a simulated operating room experience. Standardized patients (SPs) have long been recognized for their contributions to medical education, but have yet to be broadly integrated into simulations that go beyond role play scenarios, such as scrub training. Their unique skill set makes them strong candidates to lead hands on simulation-based training sessions.
Methods
Pre-clinical medical students were invited by email to sign up for one of two optional scrub training workshops in our institution’s simulation center. One session was led by a scrub technician and a senior medical student, as it has been in the past. The other training was led by specially trained standardized patients. Students were asked to complete anonymous pre and post-surveys which collected demographics, attitudes towards simulation, attitudes towards the training itself, and a brief quiz on aseptic hand hygiene. Descriptive statistics were calculated for all variables and t-tests were used to assess the relationship between groups. 
Results
Both the standardized patient group and the scrub tech group saw significant increases in their pre and post scores (0.7 to 0.9; p<0.01 for both groups). There was no appreciable difference when the post-scores of both groups (0.9 and 0.9) were compared to one another. Similarly, there was no significant difference between students’ perceived quality of the training nor their confidence in scrubbing in following the training (p=0.0805 and p=0.619, respectively). Overall, both groups saw a significant increase in their scrubbing confidence (p < 0.01).
Conclusion
Our results suggest that scrub training led by trained standardized patients is comparable to those led by scrub technicians. Both trainings were successful, as evidenced by increased quiz scores and increased scrubbing confidence. Importantly, learners did not perceive a qualitative difference between the two trainings. In the future, SP-led scrub training may lead to more flexibility in scheduling, and ultimately increased learner participation. Although already heavily utilized in medical education, scrub training may represent another area where SPs can meaningfully contribute.

The Impact of the Phyician Letter of Recommendation on Medical School Admission Demographics

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