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**Abstract:**



AMA Research Challenge 2023

Guidelines and Recommendations for Providing Disability-Competent Care for Individuals with Physical Disabilities: A Narrative Review

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Background
The relationship between manual dexterity, specialty choice, and the use of OMT in newlyadmitted osteopathic medical students remains unclear. Previous research suggests a connection between hand dexterity and surgical skill development, but there is a gap in understanding how manual skills relate to career choices and interest in OMT. This study investigates this connection, aiming to shed light on the influence of hand dexterity on career path and incorporation of osteopathic skills.
Methods
30 newly admitted RowanSOM students underwent a timed-Purdue pegboard assessment to measure their hand dexterity. The completion time was recorded, and shorter times indicated higher scores. Afterwards, the students completed a survey to determine their interest in specific specialties and their desire to practice OMT in the future. For the surveys, the “desire to practice OMT” and “the desire to pursue a surgical specialty” were quantified via a score on a scale from -2 to 2. The relationship between specialty/OMT interest and hand testing was thus explored.
Statistical analysis of the collected data was conducted using SPSS software.
Results
A non-parametric statistical analysis was performed on data collected from a sample of 30 newly admitted RowanSOM students, consisting of 17 women and 13 men, with an average age of 24.37 ± 2.798 years. Hand dexterity was measured by the time taken to complete the Perdue Pegboard exercise. Interest in a surgical specialty and OMT was measured using a scored survey on a scale from -2 to 2, with -2 representing Strongly Disagree and 2 representing Strongly Agree. There was a positive correlation between dominant hand proficiency in the assembly task and
interest in performing OMT, as indicated by a Pearson correlation value of 0.371 (p = 0.044). This suggests a statistically significant correlation between faster completion times on the Perdue Pegboard test and interest in OMT.
Conclusion
This project investigated the influence of inherent hand dexterity on medical career paths and the incorporation of osteopathic skills. It found a significant correlation between better performance on the Perdue Pegboard hand dexterity test and interest in OMT. The collected data provides support for the positive correlation between hand dexterity and the desire to practice OMT. Conducting this project on a larger scale could validate these results. If this correlation is consistently observed in future trials, it could impact the recruitment of medical school candidates and the development of skills in undergraduate pipeline programs and the preclinical years.

Exploring the Link between Manual Skills, Specialty Selection, and the Aspiration to Practice OMT in Newly Enrolled Osteopathic Medical Students

Introduction:

Hispanic women pursue breast augmentation surgery more than any other minority group.1 Additionally, breast implant removals increased by 34.4% in 2019 and by 8% in 2020, perhaps due to rising concerns for breast implant-associated anaplastic large cell lymphoma.2 However, this trend may not be reflected in all racial segments. Patient education materials (PEMs) with advanced readability can limit Hispanic patients’ health literacy and understanding of treatment plans, increasing barriers to breast implant removal and worsening health outcomes. When compared to non-Hispanic Whites, Hispanics attain less highschool and college education, have less household income, and face higher poverty rates.3 These factors negatively influence health literacy. Despite the National Institutes of Health recommending PEMs be written at the 6th-7th grade readability level, online PEMs are often difficult to read. This study assessed and compared the readability of Spanish and English online breast implant removal PEMs.


Methods:

The English and Spanish terms “breast implant removal” and “extracción de implantes mamarios” were queried on Google and the first fifty Uniform Resource Locators (URLs) for each search term were selected. Included resources were non-video, free articles. Each URL was categorized into private business (private clinics, independent practice), institutional (governmental agencies, medical schools/teaching hospitals, medical sources), and academic (journal article, book chapter) groups. To ensure analyses provided useful insights into resources used by patients rather than surgeons, academic articles were regarded as a separate entity and analyzed independently. Readability scores were generated using the Simple Measure of Gobbledygook (SMOG) and the Spanish SMOG scales.


Results:

PEMs published by private businesses comprised the majority (> 60%) of both English and Spanish articles. Overall, online breast implant removal PEMs surpassed recommended reading levels in both English (x̄ = 12.2, highschool senior) and Spanish (x̄ = 11.0, high school junior). Among PEMs in the private business category, those written in English were more difficult to read than Spanish (p < 0.00001). As a whole, English PEMs were similarly more difficult to read than Spanish PEMs (p < 0.00001, excluding academic). There were no significant differences in readability when comparing English and Spanish institutional PEMs, English private business and English institutional PEMs, or Spanish private business and Spanish institutional PEMs.


Conclusion:

Our findings show that the readability of English and Spanish materials for breast implant removal exceeds recommended levels. This discrepancy may have ramifications for certain groups as breast implant removal is a procedure that can have significant cosmetic and psychological impacts.4 It is vital that these patients are provided with educational material appropriate to their literacy level in order for them to understand the procedure, its implications, and indications. Additionally, the significant proportion of PEMs authored by private businesses may be concerning due to an inherent self-serving bias. Online information for breast implant removals should be revised and/or standardized materials should be created by healthcare providers and national organizations in order to more fully educate the public and prospective patients prior to intervention.

Are Difficult to Read Patient Education Materials Problematic? A Readability Assessment of Online Patient Education Resources Related to Breast Implant Removal and Breast Implant Illness.

Background: The recognition of cultural complications as part of the learning paradigm of medical training is slowly becoming a vital focus. An innovative cultural complications curriculum (CCM), pioneered by groups from the University of Maryland and Michigan, has been implemented within M+M teaching conferences across select institutions. Its adoption on a nationwide platform attests to its efficacy in delivering impactful social medicine education that is engaging, thought-provoking, and purpose-driven. This study aims to illuminate the journey and tangible strides achieved in integrating the CCM into our monthly M+M teaching conferences within the UPMC Plastic Surgery Department. 
Methods: We used the freely available, established, CCM toolkit online, which focuses on 12 core DEI concepts. This curriculum emphasizes an active, safe, and evidence-based discussion format. We administered pre- and post-initiation surveys to assess the department's initial interest and subsequent feedback. 
Results: We received 63 completed pre-initiation surveys that included all members of our department. 78% of respondents expressed profound initial interest in this initiative. Additionally, 64% of respondents felt positive that their colleagues are committed to learning about diversity, equity, and inclusion. We received 33 completed post-initiation survey responses from CCM attendees that represented all department members. 60% of respondents expressed either that they agreed or strongly agreed that they “learned valuable information from the CCM”. 86% and 88% of respondents either strongly agreed or agreed that “incorporating DEI principles is important for good patient care and ...for a successful workplace", respectively. 64% and 67% of respondents felt more equipped to identify Overt Bias and Implicit Bias, respectively. There was a noteworthy increase in the number of respondents who believed they possessed effective strategies to address overt bias when encountered with someone more senior in the organizational hierarchy and when it involved patients (56% vs. 46%, 77% vs. 52%; respectively). Additionally, there was a marked decrease in the number of respondents who felt ill-equipped to address implicit bias when encountering individuals at various hierarchical levels (15% vs. 38% with seniors, 6% vs. 18% with like-peers, 3% vs. 10% with juniors). 
Conclusions: Through this study, we were successful in achieving positive outcomes by implementing this established curriculum within our department. While our perspectives on this endeavor remain positive, we must acknowledge the formidable challenges we encountered during the initiation phase that could be encountered by others planning to champion this initiative within their department/division. We were able to deliver education on social medicine topics in a unique format that prioritizes sharing lived experiences and evidence-based discussion over passive learning.

Cultural ‘Complications’ Morbidity and Mortality Plastic Surgery Grand Rounds: The Pitt Plastic Surgery Experience

Background
Scar management is an integral part of postoperative care in plastic surgery. The approach may vary based on skin tone. Hence, comprehensive training on scar prevention and treatment of all Fitzpatrick skin types is important in resident education. Nationwide, plastic surgery residents use the American Society of Plastic Surgeons (ASPS) Resident Education Curriculum as an online resource during their training. A previous study found that this online resource generally does not equitably represent patients of diverse skin tones. The aim of our study was to assess the representation of diverse skin tones in the ASPS Resident Education Curriculum teaching materials specifically on scarring. We hypothesized that the modules focused on scarring do not equitably represent patients of diverse skin tones.

Methods
The ASPS Resident Education Curriculum was reviewed to select teaching modules that mentioned the term “scar” in their learning objectives. Visual aids were then identified in the selected modules. Three independent raters scored these visual aids on the Fitzpatrick scale I-VI. The Fitzpatrick scale ratings were categorized into 3 groups: I-II, III-IV, and V-VI. One-way ANOVA and Tukey’s post-test analysis were performed to compare Fitzpatrick scales I-II versus V-VI. Percent agreement was used to calculate inter-rater reliability among the raters. 

Results
Between September 8-10, 2022, we identified three modules that mentioned “scar” in their learning objectives. These included 21 visual aids: 65% reflected a Fitzpatrick scale of I-II (14±1.53), 29% a scale of III-IV (6±1.73), and 6% a scale of V-VI (1±0.58). There were significantly more visual aids categorized as Fitzpatrick I-II versus Fitzpatrick V-VI (p<0.001). We did not identify a dedicated module on teaching plastic surgery residents scar prevention or treatment. The inter-rater reliability between the three raters was 74.6%.

Conclusion
Our study demonstrates that skin tone representation in scar management teaching materials for plastic surgery residents is skewed towards Fitzpatrick scales I-II, representing the lightest skin tones. Adequate knowledge of scar prevention and treatment of all skin tones is essential given that hypertrophic or keloid scars often occur in individuals of darker skin tones. We recommend creating a dedicated scar management module in the ASPS Resident Education Curriculum containing diverse representation of skin tones.

Diversity in Scar Teaching Materials in the ASPS Resident Education Curriculum

Background
As a student, it is no easy task to endure the pace, rigor, and responsibility of medical school. Prior studies have well established that medical students experience higher rates of stress, depression, anxiety, and burnout compared to the general population. However, the most effective techniques to combat these alarming rates remain unclear. In this paper, we sought to identify the benefits of psychotherapy for medical students experiencing stress-induced mood disorders. These include an array of mental health concerns, ranging from perfectionism to suicidal ideation. Psychotherapy (I.e., talk therapy) is a method of discussing one’s life events in order to identify ways to improve their own beliefs, thoughts, and actions. Therapy can be targeted for certain mood disorders or psychopathology, and has been shown to be very effective for many people. We sought to discuss and evaluate the potential successes of therapy in reducing mental health concerns amongst medical students, while also discussing the barriers and issues that stand between the utilization of therapy in this population.
Methods
A literature review regarding the relationship between medical students and therapy was conducted using the following sites: PubMed, Google Scholar, NIH, and ASA Psych. There were no exclusion criteria, allowing inclusion of an array of articles, including primary literature, clinical trials, and case-studies. Articles and websites deemed to contain peer-reviewed evidence were read carefully and used as relevant citations.
Results
While overall current data is limited, several studies showed improvement in medical student mental health after trials with therapy and therapy-learned techniques including mindfulness. The primary barrier from pursuing therapy as a means of mental health support was stigma. This stigma is a result of the competitive and invasive nature of medical education, with students fearing that seeking mental health help would make them perceived as weak by their peers and evaluators. Students also attribute issues such as accessibility, busy schedules, and financial cost to their hesitancy to try therapy. 
Conclusion
While still relatively underexplored, the preliminary outcomes of medical students participating in therapy is promising for improvement of stress-induced mood disorders. Medical school curriculums must prioritize student wellness by dismantling barriers of stigma, accessibility, and negative self-perception in order to promote options such as therapy. We believe this research should be taken further by looking into patient outcomes after seeing providers who have previously gone to or are currently in therapy. 




Psychotherapy Usage by Medical Students: ​A Review of Potential Benefits and Barriers


Background: 
Studies have shown that burnout can begin as early as medical school and can worsen in residency. Research from the National Institute of Health (NIH) shows burnout rates as high as 50% in the resident population. The Accreditation Council of Graduate Medical Education (ACGME) and the American Medical Association (AMA) have developed recovery plans to fight system level drivers of burnout, promote physician wellbeing, and advocate for better learning environments for trainees. The Maslach Burnout Inventory (MBI), and its subscales; Occupational Exhaustion (OE), Depersonalization (DP), and Professional Accomplishment (PA), are commonly used to determine levels of burnout among resident physicians. A common problem among residency administration is how to incorporate meaningful, longitudinal changes that decrease burnout. The MBI is reliable in determining if burnout exists, but less reliable in assessing if interventions are useful, as burnout often rebounds and is typically resistant to interventions longitudinally. The authors developed and co-led quarterly focus groups, which were compared to simultaneously collected aggregate MBI scores to evaluate the reliability and potential benefits of focus groups in assessing burnout and developing interventions.   

Methods:
Semi-structured focus groups (8) for psychiatry residents were led from July 2022 to July 2023, separated by PGY level (PGY1 or PGY2). The residents completed an online MBI prior to the scheduled focus group. A quantitative analysis was completed quarterly and burnout scores were calculated and compared in aggregate longitudinally, averaged by (burnout subscale x PGY cohort x quarter). The focus groups were transcribed and analyzed for positive longitudinal themes, negative longitudinal themes and actionable items to combat burnout. The content was also analyzed for similarities to the MBI questionnaire. 

Results: 
Longitudinal trends in MBI scores were found among the PGY cohorts which showed differences in burnout severity. The PGY1 residents showed worse levels of OE, DP and PA, suggestive of more severe burnout. PGY2 residents’ rates of OE and DP also worsened but less significantly, while PA stayed level throughout the year. The content expressed in the focus groups were comparable to the MBI, with an additional 19 to 30% additional data on longitudinal themes and actionable items. These themes were further analyzed and organized into nine major themes. 

Conclusion: 
The differences in severity of burnout between cohorts were dependent on PGY year and quarter. The focus groups demonstrated actionable items and positive longitudinal themes that could be beneficial in shifting the discussion of implementing interventions to combat resident burnout.  

The MSBI Psychiatry Residency Burnout Pilot Study: Longitudinal Trends and Themes of Burnout Through Focus Groups

Background:  Traumatic brain injury (TBI) is one of the major public health issues that is being faced by healthcare professionals. CDC has reported a burden of 223,1135 TBI-related hospitalizations in 2019 with another 64,362 deaths reported due to TBI in 2020 (CDC 2023). TBI is classified into different categories (mild, moderate, and severe) in accordance with the symptoms. Research has shown that TBI affects the cognitive domain of the brain along with mood and neurological symptoms. The pathophysiology is not very well understood and as such no treatment options have been effective up to date. Some postmortem studies have indicated accumulation of beta-amyloid and taupathy in TBI similar to AD. Hyperphosphorylation of tau proteins and decreased lysis of APP is hypothesized to be causing this accumulation (Leeds et al 2014; Shim and Stuzmann 2016). The role of medications that can help with the reversal or slowing of these disease patterns cannot be underemphasized and one such medication is Lithium. Lithium is an indirect GSK-3 inhibitor and several studies in rodents have shown it to be effective in improving symptoms of anxiety, depression, and cognitive symptoms associated with TBI as it is seen that GSK3 beta pathway is activated in TBI. One study showed lithium administration at 15 minutes and once daily for 2 weeks decreased lesion size, slowed the death of neurons, and inhibited the ongoing inflammatory processes (Shim and Stutzmann 2016; Matteo et al; Dell’Osso 2016; Fenshan et al 2013; Zhu et al 2010). The neuroprotective effects of lithium are demonstrated in other rodent studies (for Parkinson’s disease) where improved behavioral test performance was seen along with a decrease in aggregated alpha-synuclein. These effects were also appreciated for rodents who had TBI and Alzheimer’s Disease by decreasing pro-inflammatory interleukin 1B, reduced depressive behavior, helps increase dopaminergic receptors, decreased APP and neurofibrillary tangles respectively (Matteo et al 2021; Haupt et al 2021; Ciftci et al 2020; Carlson & Dixon; Carlson et al, 2017; Yu et al 2012). 



Method:  Pubmed, SCOPUS and Web of Science literature databases were screened and filtered by using search terms, inclusion/exclusion criteria with articles/trials from 2010 to date. These gave us a result of about 221 citations from the databases. We further reviewed these citations and after careful review a total of 16 papers were reviewed for this abstract. 



Results: Although research is sparse in terms of Lithium use and TBI, data clearly shows that it can have neuroprotective effects that can be useful for patients with TBI. The mechanism of action of lithium including the reduction of neuroinflammation, indirect GSK3 inhibition and increase in dopaminergic receptors co-relate with possible insults that are seen in TBI. 



Conclusion: Further research is needed in the future on humans who have suffered from TBI and the emergent use of lithium in these patients. The mechanism of action of lithium can explain the benefits that it may provide to patients with TBI. The goal in the future could be to possibly help in formulating a treatment protocol for patients have had a TBI.

Mysterious Role of Lithium in the treatment of traumatic brain injury - a new insight

Background
• To assess knowledge regarding MDI and its technique amongst healthcare
personnel and to understand its importance.
• To spread awareness regarding the same via educational tools
• To compare the understanding of the technique before and after the use of
educational tools.
Methods
A study group of 213 participants consisting of residents from the
departments of internal medicine (48), pediatrics (36), respiratory medicine
(8), community medicine (11) and staff nurses (110) of all departments were
selected as these acquire most of the cases related to the usage MDI. They
were provided with educational tools. A comparison was made in their
knowledge about the technique of MDI before and after the use of education
tools using a pre-validated questionnaire and the results were obtained in
terms of the mean scores.
Results
The mean score attained by residents of the internal medicine department
was 6.5/16 (standard deviation (S.D)-2.44) in the pre-test and 12.82/16 (S.D-
2.61) in the post-test with an improvement of 6.32 marks (t-value-10.00) and
a p-value of 0.0001. The residents in the pediatrics department had a mean
score of 5.76/16 (S.D-2.36) in the pre-test and 12.36/16(S.D-3.47) in the post
test with an improvement of 6.60 (t-value-10.22) and a p-value of 0.0001. The residents in respiratory medicine had a mean score of 6.33/16(S.D-2.87) in the pre-test and 13.66/16(S.D-2.42) in the post-test with an improvement of 7.33 marks(t-value-4.82) and a p-value of 0.005. The residents in the community medicine department had a mean score of 3.90/16 (S.D-1.37) in the pre-test and 10.09/16 (S.D-3.08) in the post-test with an improvement of 6.18 marks (t-value-6.43) and a p-value of 0.0001. The nurses had a mean score of 4.81/16 (S.D-2.43) in the pre-test and 11.75/16 (S.D- 2.94) in the post-test with an improvement of 6.93 marks (t-value 18.33) and a p value of 0.0001.
Conclusion
Residence of all departments performed significantly better after audiovisual educational tools. Maximum improvement was seen amongst the nurses. Most of the healthcare personnel had better knowledge regarding the usage of the MDI technique after the education tools. In developing countries like India where the number of asthma patients is so high, formal and systematic training should be provided to the healthcare personnel who are directly involved in prescribing and instructing the use of MDI technique to patients to improve patient outcomes by increasing adherence and to decrease healthcare burden by decreasing the number of exacerbations.

IMPACT OF AUDIO-VISUAL AIDS IN IMPROVING THE KNOWLEDGE OF THE
METERED DOSE INHALER (MDI) TECHNIQUE AMONG HEALTHCARE
PERSONNEL

Background
The current radiology education provided to medical students and non-radiologist clinicians is not adequately effective or comprehensive, leaving them underprepared to handle the immense quantity of radiological studies they will be responsible for in the future practice. Furthermore, imaging over-utilization can harm patients and add to the burden on the already overstressed radiology workforce. This study explores the implementation and efficacy of an online, interactive, case-based radiology education tool, Wisdom in Diagnostic Imaging (WIDI) Case- Based Intro to Radiology (CBIR). The 140 cases include a patient history, physical exam, relevant labs, ACR appropriateness criteria, key images, full DICOM sets, video explanations, radiology reports, learning points, and socioeconomic factors. Learners are asked to make a provisional diagnosis, select appropriate imaging, assess imaging findings, determine acuity and need for further imaging, make a final diagnosis, devise an assessment and plan, and are given feedback on their responses.

Methods
A focus group consisting of one undergraduate, seven medical students, nine physician assistant students, and three PhD students participated in this study. We tested three different teaching methods: a didactic approach without WIDI, a proctored didactic approach using WIDI,
Ó 2023 American Medical Association. All rights reserved.
and a flipped classroom approach using WIDI. An online survey was conducted to assess student preference and feedback on these methods and the use of WIDI in their curriculum.

Results
Most students preferred the proctored didactic approach with WIDI. They reported that the platform complemented their curriculum and encouraged critical thinking. Most students noted that the modules covered adequate clinical and imaging details and enhanced their skills in imaging interpretation. Despite limitations of a small sample size and reliance on self-reported outcomes, this study suggests that the WIDI platform could be integrated into PA and medical school curricula throughout the US, offering a standardized radiology curriculum.

Conclusion
The UF Wisdom in Diagnostic Imaging (WIDI) appears to be a promising tool for modernizing radiology education, improving imaging interpretation skills, and enhancing appropriate imaging selection among non-radiologist medical learners. By offering structured, active learning with iterative feedback on image interpretation and utilization through this platform, we can potentially minimize disparities in imaging skills acquired across medical and PA schools and improve proficiency in radiology interpretation and utilization. This may ultimately contribute to a reduced workload for radiologists and lead to improved patient outcomes.

Enhancing Radiology Education with a Case-Based Intro to Radiology on the UF WIDI e-Learning Platform

Purpose 
The anatomy lab is often the first-time medical students are exposed to complex, 3-dimensional relationships of anatomy, as well as the specialty of radiology. Unfortunately, in cadaver-based labs, the anatomy as well as the intimate association between deep internal organs is lost during dissection. This study seeks to create a protocol for accurately capturing soft-tissue data from embalmed organs using Diffusible Iodine-based Contrast-Enhanced Computed Tomography (diceCT). This study compares and contrasts how 1% and 3% iodine concentrations penetrate pig hearts and affect soft tissue resolution under standard hospital CT scans.1

Methods/ Materials
Two hearts from Sus domesticus (Suidae) were used, as pigs have proven to be useful analogs for human clinical anatomy.2 Specimen 1 weighed 373 grams (Fig. 1) and Specimen 2 weighed 388 grams (Fig. 2). Following the methods of Gignac et al. 1, both specimens were soaked in a 20% sucrose solution for 48 hours to prophylactically reduce dehydration from the iodine agent. Specimen 1 was then placed in a 1% iodine solution and Specimen 2 into a 3% iodine solution. Both specimens were stored in a dark room for four weeks. Following the iodine soak, the specimens were taken to St. Bernard’s Imaging facility for CT scanning using a GE LightSpeed VCT 64 slice CT scanner at a slice thickness of 0.625 mm. CT data were exported in DICOM format for reconstruction using the imaging and 3D analysis software, Avizo (ThermoFisher Scientific).

Results
Both specimens had a Hounsfield range of -1115 to 3071 and generated two high-value peaks. The second peak of the 1% heart quickly decayed whereas the second peak of the 3% heart almost plateaued, indicating more voxels (3D pixels) in the higher positive range, and thus greater contrast for the 3% solution specimen. 
Volume rendered images of the 1% and 3% hearts in lateral view show fainter contrast at the same Hounsfield range for the 1% heart. Overexposure along the outer surface of the 3% heart specimen indicated rinding from the high iodine uptake along the surface.

Conclusion 
Our results found that a 3% solution was most effective at penetrating the muscular wall of the heart and better capturing the soft-tissue anatomy. However, extensive “rinding” along the outer surface indicates that a 4-week soaking period may be too long for such a relatively high concentration.

The next phase of this study is to have these specimens μCT scanned using the μCT scanner on the Long Island campus of NYITCOM. This will allow us to determine how effective this current concentration was at capturing the different tissues in the heart. Our future work aims to target the best mix of iodine concentration and soaking time for the most effective contrast. For instance, our 1% solution could provide equivalent or more contrast at the cost of a substantially longer soak time. In contrast, our 3% solution had a high amount of rinding on the perimeter at only 4 weeks. It is possible that an iodine solution of 1.5–2% is the most appropriate mix. The appeal of this protocol is that it can be injected into the blood vessels of cadaveric specimens, allowing the vessels to distribute the iodine more naturally and with faster uptake; a process called SPICE-CT. This would allow images to be generated with the heart still inside the cadaver. In this manner, complex 3D relationships can be maintained and studied. 




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Guidelines and Recommendations for Providing Disability-Competent Care for Individuals with Physical Disabilities: A Narrative Review

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Exploring the Link between Manual Skills, Specialty Selection, and the Aspiration to Practice OMT in Newly Enrolled Osteopathic Medical Students

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