United States

The integration of point-of-care ultrasound (POCUS) curricula in undergraduate medical education has become increasingly common over the last decade. Many studies have shown the benefits of POCUS curricula on improving medical student performance on assessments including anatomy exams and objective structured clinical examinations. However, there is substantial variation of POCUS curriculum across U.S. medical schools, and of the schools with an approved POCUS curriculum, few have longitudinal four-year programs with tailored projects geared to prepare medical students for residency. Specifically, a recent study emphasized the necessity of future studies assessing student evaluations in clerkships with significant POCUS use. Although many specialty programs include POCUS competencies as part of their residency milestones, ultrasound is not considered a required entrustable professional activity (EPA) to graduate medical school, which poses a challenge for rising residents in POCUS-heavy specialties. Our focus is to identify the advantages of completing a four-year POCUS longitudinal curriculum, which includes a residency-specific project, in preparation for graduate medical education. We developed two IRB-approved surveys, one for medical students involved in ultrasound education and one for clerkship and residency directors at local clinical sites, to assess perceived preparedness for use of POCUS in students’ desired specialties. The students’ degree of involvement across all four years of undergraduate medical education was stratified and comparatively assessed to designated outcomes. Students were asked about degree of involvement in ultrasound curriculum, level of proficiency in various procedures, performance during clerkship rotations, and United States Medical Licensing Examination (USMLE) Step 2 scores. Clerkship and residency program directors were also asked about impact of ultrasound education on student performance during rotations and on performance during residency. Preliminary findings indicate residency directors strongly agree that ultrasound curriculum is beneficial to students’ clerkship experiences. Directors also indicate that residents who have completed ultrasound curriculum have advanced performance in their specialty and can better integrate bedside ultrasound results into patient care plans. For students, we expect that those who complete the four-year POCUS curriculum will perform the highest on all assessments and feel most prepared to enter their desired specialty residency programs. Some limitations to this study may include the period of time the longitudinal curriculum has been in place, thus limiting the number of students who have completed all program requirements. Overall, the longitudinal POCUS curriculum is expected to demonstrate an effective transition-to-residency model and encourage improvement of ultrasound education programs in other medical institutions.

2023 AMA Research Challenge

A retrospective longitudinal cohort study of medical student ultrasound curriculum involvement in determining clerkship and post-graduate success

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Background 
Doximity, a platform for healthcare professionals, aids residency applicants in program ranking decisions, despite debate over its rankings' reliability due to a lack of objectivity. Nevertheless, studies reveal that Doximity's Annual Residency Navigator Tool (DRN) rankings influence program selection. This study aims to analyze the impact of Doximity rankings on applicant decision-making.

Methods 
A systematic review guided by PRISMA was conducted and PubMed, Google Scholar, and Web of Science databases were queried to identify DRN-related articles. Covidence was used for screening. The review included studies evaluating DRN rankings' usage by residency applicants.

Results 
A total of 8 of 266 screened articles were included. Survey data were analyzed from 5,068 residency applicants: 22% emergency medicine, 16% general surgery, and 12% internal medicine. Common themes encompassed program DRN reputation importance (50%), calls for enhanced DRN objectivity (50%), and the significance of program online presence (38%) and applicants’ mentors (25%). Perceived Inaccuracies included DRN's survey sampling bias and construct validity.

Conclusion
Despite applicant perception of inaccuracy, DRN rankings influence program preferences and applicants’ residency program rank lists. This study recommends further research efforts on an objective ranking system for better applicant fit assessment.

Ranking U.S. Medical Residency Programs: A Systematic Review and Critical Analysis of Doximity’s Annual Residency Navigator Tool

Background
Shortages in clinical skills faculty exist nationwide, affecting medical students' clinical skills education. Moreover, medical students have previously expressed that clinical supervisors may not fully understand their learning struggles due to the knowledge gap between them. Teaching assistants (TA) may help address both challenges. However, current literature on the efficacy of TAs in teaching clinical skills is mixed. Improving upon previous research, this study evaluates the viability of second-year medical students as clinical skills TAs by providing extensive, standardized retraining before near-to-peer instruction.
Methods
Six second-year medical students and six faculty taught physical examination techniques for the musculoskeletal system to 130 first-year medical students (M1). Prior to instruction, second-year TAs underwent retraining in physical examination techniques by a clinical expert, instructional videos, and standardized patients (SP). M1s were randomly assigned to be taught by either faculty or TAs each week. Each clinical skills session included the following: 1) pre-session study of physical exam instructional videos and protocol; 2) 20-minute large group demonstration conducted by a faculty expert with an SP; 3) one-hour deliberate practice on an SP with either a TA or faculty member (randomized 3-4 students per group); and 4) evaluations in randomized groups of 7-8 students co-led by a faculty member and TA. Faculty administered evaluations while TAs scored them based on predetermined criteria. Both faculty and TAs were blinded to whether M1s had been taught by faculty or TAs. Formative evaluations covered observation, palpation, and special tests, with a maximum score of 12 points and minimum score of 0. End-of-course OSCE scores were analyzed for differences among students receiving zero, one, two, three, or four TA-instructed sessions.
Results
No significant difference was found between evaluation scores of M1s taught by faculty and those taught by TAs across each week. During week one, faculty-taught M1s averaged a score of 10.38 while TA-taught M1s averaged 10.92 (p=0.064). In week two, both faculty-taught and TA-taught M1s scored 10.14 (p=0.99). In week three, faculty-taught and TA-taught M1s scored 11.06 and 10.56, respectively (p=0.13). In week four, faculty-taught M1s averaged 11.48 while TA-taught M1s averaged 11.37 (p=0.57). When stratified by number of TA-instructed sessions received, OSCE scores yielded no significant difference.
Conclusion
With proper training, near-to-peer TAs are competent clinical skills instructors. When access to trained faculty is limited, TAs may viably supplement faculty shortages without sacrificing quality of instruction.

Near-to-peer teaching assistants effectively supplement clinical skills instruction

Background
As physician shortages increase in the United States, many medical schools across the country have established regional medical campuses (RMCs) to increase class size. The University of Missouri-Columbia (MUSOM) created an RMC, the Springfield Clinical Campus (SCC), in 2016. All students spend the preclinical years at the central campus in Columbia, then either continue in Columbia or move to Springfield for the clinical years. 
Some research has been published on the correlation between RMC training and in-state postgraduate training. However, no publications have discussed the relationship between clinical RMC training and in-region postgraduate training. Geographic regions have become important for residency applicants in recent years as regional preferencing has been integrated into the ERAS application. For the 2022-2023 ERAS cycle, all specialties participated in geographic preferencing except for obstetrics and gynecology (OBGYN) and emergency medicine. This has changed for the upcoming 2023-2024 application cycle, in which OBGYN applicants are now encouraged to specify up to three preferred geographic regions. We collected data on whether central versus regional clinical campus was correlated to postgraduate training in an outside region prior to the implementation of geographic preferencing using OBGYN match results of graduates of MUSOM.

Methods
We utilized publicly available OBGYN match data from 2018-2023 for MUSOM. Residency programs were labeled by geographic region according to the regional designations utilized by the Electronic Residency Application Service (ERAS). A Fisher exact test was performed to calculate the two-tailed p-value comparing the proportion of students at each campus who matched in region versus out of region.

Results
In total, 34 students matched into OBGYN from MUSOM and elected to make this data public. Of these, 8 students attended the SCC and 26 students attended the central campus. At the SCC, 25% of students matched in region, while 75% matched out of region. At the central campus, 38% of students matched in region, while 62% matched out of region. There was no statistical difference between the campuses for the proportion of students matching in region versus out of region (p=0.6809). 

Conclusion
No difference was found between the RMC and central campus for the proportion of students matching in region versus out of region for OBGYN residency. Subsequent research following implementation of geographic signaling would likely be useful for elucidating trends among the campuses. Future studies may also investigate this correlation in medical schools with RMCs in which both preclinical and clinical years are completed at the RMC.


Geographic Locations of Obstetrics and Gynecology Residency Programs Matched by Regional and Central Campus Graduates

Background: The Standardized Patient (SP) Program is a potential avenue through which ethnic minority medical students experience bias, due in part to the inherent subjectivity of an SP’s evaluation of the doctor-patient interaction (DPI). In most training programs, medical students are assessed on their clinical and interpersonal skills via simulated encounters where students assume the doctor role and SPs act as patients. Previous multi-institutional research showed that African American students received a lower group performance score than white students when evaluated by SPs on interpersonal skills. Subsequently, this may result in differential attainment, a phenomenon where graduates of underrepresented backgrounds become subject to worse outcomes during residency selection and specialty training. This qualitative study unprecedentedly compares the perspectives of ethnic minority medical students with that of SPs in the context of DPI. We additionally sought to identify areas within the SP Program that may perpetuate bias and ultimately impact the minority student experience.
Methods: Participants were recruited from a single U.S. allopathic medical school. A total of 14 medical students from the second-year class, 11 of which self-identified as non-white ethnic minorities, were distributed into 6 focus groups. A total of 9 SPs were interviewed, 3 of which self-identified as non-white ethnic minorities. All interviews were then transcribed and analyzed using a combination of first-cycle coding methods in NVivo. In the final stages, we examined the data to determine frequent themes across the study populations.
Results: The results demonstrated conflicting sentiments between SPs and students. Although SPs described an intensive training process that promoted standardization of DPI scoring across SPs, ethnic minority students reported high interSP variability, referring to the variation in the interpretation of a student’s communication skills by SPs. The consensus amongst minority students was that SPs evaluate students more leniently in interactions where the SP and student share ethnic identities. Students endorsed a constant internal awareness of their ethnicity during these simulated encounters as a consequence. In particular situations, that awareness pressured students into altering their personality in order to receive evaluations comparable to their white colleagues.
Conclusion: Although medical education administrators have begun shifting their attention towards diversity, equity, and inclusion initiatives, there has been minimal focus on the key perspectives necessary to navigate this space. Our research analyzes those perspectives as an important first step towards acknowledging and effectively mitigating bias in medical education programs. Next steps involve restructuring the SP training process to incorporate unconscious bias training.

Two Sides to Every Story: Comparing Perspectives of Ethnic Minority Medical Students and Standardized Patients

This study evaluated the Collaborative Approach to Learning Medicine (CALM) program at Rutgers New Jersey Medical School, a peer-to-peer educational support initiative for first-year medical students. A pre-post study was conducted in the 2022-2023 academic year, analyzing survey responses from 47 participants. Pre-survey results indicated students' perceptions of the program, with question banks being the most effective resource (mean score: 4.2) and student-led tutoring as the least effective (mean score: 3.5). After participation, the effectiveness of overview sessions, review sessions, and anatomy course videos significantly increased (p<.05). Qualitative feedback emphasized improving question quantity and quality. This study highlights the CALM program's effectiveness in peer-to-peer teaching while recommending resource allocation to enhance frequently used components.

Perceptions of Medical Students Towards the Effectiveness of the Collaborative Approach to Learning Medicine Program

Background
Given increasing competition for residency positions and emphasis on USMLE performance in residency application evaluation, medical students must often prioritize studying for the USMLE over other responsibilities. There has been an explosion in the number and availability of USMLE test preparation resources over the past two decades as students use these resources for board exam preparation and as a supplement to their medical school curriculum. With increased pressure to excel in both school and board exams, these resources have become an increasingly valuable, yet expensive necessity for students. To date, comprehensive review of the number of students using third-party resources across multiple-institutions has not been performed. This systematic review aims to determine the commercial third-party resources used by medical students as supplements to the standard medical curriculum or as aids in USMLE board exam preparation.
Methods
A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy designed by a medical librarian was used to retrieve articles from Embase.com, Ovid-Medline All, Scopus, Web of Science, and ERIC (ProQuest). Inclusion criteria was original research articles centered in US medical schools that included information on student use of third-party commercial resources. The meta-analysis was performed for resources that had a minimum of three studies investigating student use of that resource. Effect size was computed for each study and a pooled effect summary with 95% confidence intervals was calculated to summarize across studies.
Results
A total of 1056 citations were screened with 19 full-text studies included in this review. Of these, 21% had a study population comprised of osteopathic medical students, 79% had a study population comprised of allopathic medical students, and 5% was comprised of both. 22 unique third-party resources were examined across all studies, with meta-analysis revealing the three most common commercial resources used by medical students to be First Aid, UWorld, and Pathoma with effect summaries of 78.22% (39.20%-117.23%), 75.96% (53.61%-98.31%), and 63.64% (36.86%-90.42%) respectively. 
Conclusion
In this systematic review and meta-analysis, we synthesized findings from 19 different studies investigating the use of 22 commercial third-party resources by medical students with the most popular being First Aid, UWorld, and Pathoma. In light of the widespread utilization of third-party resources, medical faculty should consider adapting their curriculum to better cater to the learning needs of students and establish systems that ensure equitable access to verified commercial resources.

Unlocking Medical Student Success: A Systematic Review and Meta-Analysis of Third-Party Resources Used as Supplements for Medical Education and USMLE Board Preparation 

Background
Imposter Phenomenon (IP) involves a pattern where individuals doubt their skills and worry they will be exposed as frauds. Students who experience IP tend to discount positive feedback and their accomplishments. Furthermore, IP predisposes to depression, anxiety, and suicidal ideation. Of concern, the estimated prevalence of IP in medical students ranges from 22.5%-46.6%. Despite this, there is scant empirical literature exploring IP in clinical medical students. The few studies that exist suggest that aspects of medical education may contribute to IP, but there is currently little longitudinal data exploring this. Therefore, the purpose of this study is to assess IP in third-year medical students prior to and after clerkships. 
Methods
A single class of medical students was surveyed immediately prior to (Time 1) and after clerkships (Time 2) using the Clance Imposter Phenomenon Scale. Data was analyzed using Wilcoxon signed-rank tests to determine significant differences in IP. After Time 2, students participated in semi-structured interviews to assess their personal experiences with IP. Interviews were conducted using a predesigned interview guide consisting of nine open ended questions. Thematic analysis was performed to determine protective and contributing factors to IP. 
Results
Of the 141 students, 18 students took both surveys and 10 participated in semi-structured interviews. There was no statistically significant difference in IP scores (p=0.970), with scores indicating “frequent imposter feelings”. Thematic analysis of student responses revealed protective factors such as increasing confidence, safe learning environments, and role model/peer interactions. Contributing factors included making comparisons to other students, perceived knowledge gaps, and evolving/new stressors. 
Conclusion
Medical students in our study reported frequent imposter feelings, with no significant difference in scores. These scores are comparable to other studies examining IP during clerkships. Students in our study suggested that while they built confidence in the clinical domain, other stressors elicited feelings of doubt and imposterism, such as upcoming board exams. Furthermore, comparisons to other students and perceived knowledge gaps can elicit these feelings. Despite this, students found that conversations with mentors and peers can build comradery and reduce feelings of IP. As other studies have noted, institutional culture is important. Students in our study suggested that preceptors who create a safe learning environment helped reduce IP feelings. Institutions may benefit from encouraging this type of dynamic, while also creating opportunities for students to build comradery during clerkships. 




A Mixed-Methods Longitudinal Assessment of Imposter Phenomenon in Third-Year Medical Students

Background:
Wayne State University School of Medicine administers an annual Independent Student Analysis (ISA) survey to gauge student feedback on a continuous spectrum. One topic of dissatisfaction in previous ISA surveys was financial aid and debt management counseling. WSUSOM currently has two financial aid officers in place for the M1-M4 class, approximately 1,200 students. The financial aid office provides information from their website rather than a one-on-one customized approach. Updates regarding deadlines to fill for FAFSA, scholarships, and resources for debt management are sent to students via newsletters quarterly. 

This study aims to gather and analyze student data using the ISA survey to develop long-term solutions to improve the student body’s experience with debt management and financial aid.

Methods:
Since there was proven dissatisfaction with financial aid on the previous ISA, the committee decided to remeasure this item. A Likert scale was used, and students were given the range option between “very satisfied” and “very dissatisfied. Students were also given a free response portion to offer narrative feedback. The survey was then analyzed, and free-response answers were appropriately coded. Following the survey analysis, the committee brainstormed and presented solutions to the administration. They then worked together to implement the suggested solutions. 

Results:
A total of 963 students from all four classes (M1-M4), responded to the survey question about the adequacy of debt management offered to students, which was a 99.6% response rate. The results showed that 20.5% of these students were either “dissatisfied” or “very dissatisfied.” In comparison, 41.7% were “satisfied” or “very satisfied” with students’ debt management counseling services. 

Comparably, 962 total students from all classes responded to the survey question about the quality of finance, with 23.8% combined “dissatisfied “or “very dissatisfied” and 56.8% students either “satisfied” or very satisfied” about the quality of financial aid administrative services being provided.

Conclusion 
Improved financial education resources are needed to prepare students for life after medical school. Debt management counseling should be integral to M1 orientation and frequently offered at information sessions and one-on-one counseling appointments. To improve students’ satisfaction, the ISA committee suggested continued efforts to improve services provided by the financial aid administration. This includes increasing personnel to attend to students’ needs, increasing the frequency of the financial aid newsletter distribution, publicizing pertinent information about financial resources, and increasing appointment times for students needing immediate assistance. Additionally, having a more transparent scholarship application process was suggested.


Student Perceptions on Debt Management and Financial Aid Counseling: Solutions for Administration

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A retrospective longitudinal cohort study of medical student ultrasound curriculum involvement in determining clerkship and post-graduate success

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