United States

Background
Annually, close to 290,000 adult patients experience in-hospital cardiac arrest in the United States. Internal medicine residents in our program felt the need for code blue training and simulation sessions to run in-hospital cardiac arrest. We conducted a quality improvement project to enhance residents’ knowledge, readiness, and confidence in leading code blue.

Methods
Residents had mock code simulation sessions every three months over 9 months (July/2023-April/2024) at Northwestern Medicine Huntley Hospital&#39;s simulation lab. In each session, residents were divided into two teams. These sessions aimed to be interactive, one team performed a scenario during each session while the other team observed, followed by a debriefing session to discuss what went well and what could be improved. The simulations focused on the roles of code blue leaders, rhythm recognition, and ACLS protocols. Pre-mock code session surveys were emailed to residents to assess their overall knowledge of ACLS protocol (medications, doses, ability to do other tasks like chest compressions, recording...) and confidence in leading code blue. Surveys included questions with a rating scale from (1-5). Following the mock code sessions, we sent post-session surveys that mirrored the initial ones, to reevaluate residents’ knowledge after the intervention.
We used McNemar’s test to determine the significance of change between the 2 surveys before and after intervention. 

Results
Of the 39 residents in our internal medicine residency program, 86.8% felt that code blue simulations significantly helped them. A significant increase was observed in residents&#39; knowledge of code blue leader roles with 42.1% feeling &quot;Very knowledgeable&quot; compared to 3% before (p = 0.05). Confidence in leading code blue also rose significantly with 44.7% feeling &quot;Confident&quot; compared to 18.1% before the intervention (p = 0.008). Knowledge of the ACLS algorithm improved significantly with 44.7% feeling &quot;Very Knowledgeable&quot; compared to 18.1% before (p = 0.025). Knowledge of ACLS medications and doses also increased significantly with 29% feeling &quot;Very Knowledgeable&quot; compared to none before (p = 0.011). While there was no significant change in interpreting rhythm strips during a code blue, more residents reported running code more frequently post-intervention (42% vs 30.3%).

Conclusion
Most residents believed that code blue simulation sessions helped them run code blue confidently. Residents&#39; confidence in leading code blue and knowledge of the ACLS algorithm increased after mock code simulation sessions. We anticipate that this project will positively impact patients’ outcomes following in-hospital cardiac arrest. Therefore, we plan to continue conducting these sessions annually for incoming interns.

AMA Research Challenge 2024 

Optimizing Internal Medicine Residents Response to In-Hospital Cardiac
Arrest: A Quality Improvement Project

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AMA Research Challenge 2025 

Join the AMA Research Challenge poster symposium and semifinals to explore top research posters and score posters in the semifinals (an AMA member exclusive opportunity).

Background
Annually, close to 290,000 adult patients experience in-hospital cardiac arrest in the United States. Internal medicine residents in our program felt the need for code blue training and simulation sessions to run in-hospital cardiac arrest. We conducted a quality improvement project to enhance residents’ knowledge, readiness, and confidence in leading code blue.

Methods
Residents had mock code simulation sessions every three months over 9 months (July/2023-April/2024) at Northwestern Medicine Huntley Hospital's simulation lab. In each session, residents were divided into two teams. These sessions aimed to be interactive, one team performed a scenario during each session while the other team observed, followed by a debriefing session to discuss what went well and what could be improved. The simulations focused on the roles of code blue leaders, rhythm recognition, and ACLS protocols. Pre-mock code session surveys were emailed to residents to assess their overall knowledge of ACLS protocol (medications, doses, ability to do other tasks like chest compressions, recording...) and confidence in leading code blue. Surveys included questions with a rating scale from (1-5). Following the mock code sessions, we sent post-session surveys that mirrored the initial ones, to reevaluate residents’ knowledge after the intervention.
We used McNemar’s test to determine the significance of change between the 2 surveys before and after intervention. 

Results
Of the 39 residents in our internal medicine residency program, 86.8% felt that code blue simulations significantly helped them. A significant increase was observed in residents' knowledge of code blue leader roles with 42.1% feeling "Very knowledgeable" compared to 3% before (p = 0.05). Confidence in leading code blue also rose significantly with 44.7% feeling "Confident" compared to 18.1% before the intervention (p = 0.008). Knowledge of the ACLS algorithm improved significantly with 44.7% feeling "Very Knowledgeable" compared to 18.1% before (p = 0.025). Knowledge of ACLS medications and doses also increased significantly with 29% feeling "Very Knowledgeable" compared to none before (p = 0.011). While there was no significant change in interpreting rhythm strips during a code blue, more residents reported running code more frequently post-intervention (42% vs 30.3%).

Conclusion
Most residents believed that code blue simulation sessions helped them run code blue confidently. Residents' confidence in leading code blue and knowledge of the ACLS algorithm increased after mock code simulation sessions. We anticipate that this project will positively impact patients’ outcomes following in-hospital cardiac arrest. Therefore, we plan to continue conducting these sessions annually for incoming interns.

poster

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At the conclusion of this event, the AMA will announce the top five finalists who will advance to the AMA Research Challenge finals, present their research to an elite panel of judges, and compete to win a $10,000 grand prize presented by Laurel Road.<br><br>

### Grand Prize Sponsor

AMA would like to thank Laurel Road for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road is not involved in winner selection process. The winner will be announced on February 20, 2025 during the AMA Research Challenge finals. Payment of the grand prize will be directly from Laurel Road. See the AMA Research Challenge Official Rules for terms and conditions.

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Appropriate use of radiological studies is of utmost importance in medical practice, guiding care and reimbursement. The American College of Radiology Appropriateness Criteria (ACR-AC) is a free, online evidence-based resource dedicated to supporting practitioners with radiology decision-making. However, this resource has historically been underutilized by physicians and medical students, with those groups often opting to use alternative resources such as UpToDate
(UTD). Increasing awareness and user-friendliness of the ACR-AC within medical education is necessary to integrate regular use of this resource in practice. This study seeks to investigate medical student performance with and perception of the ACR-AC and UpToDate when presented with radiology decision-making cases.

Methods
First-year osteopathic medical students were presented with a clinical case and utilized either UpToDate or ACR to assist in determining the most appropriate imaging modality for the case. Following the case, students were surveyed to assess their familiarity with each resource, its effectiveness in establishing a differential diagnosis, ease of selecting the appropriate imaging, perceived usefulness, impact on confidence in imaging selection, and likelihood of future utilization. The accuracy of their decisions was also evaluated based on which resource they used. 

Results
Our survey had 82 respondents for the UTD group, and 83 respondents for the ACR group. The results showed that more students have used UTD over ACR coming into the study (20% vs 8%, p=0.01). The students also more strongly agreed that UTD was more helpful in establishing a differential diagnosis for the cases (56.1% vs 49.4%, p= 0.04). However, students found that ACR was easier to use as a resource for determining the appropriate imaging modality (3.9 vs 4.2, p=0.02). The accuracy of the tests showed a trent towards significance with case one showing 92.1% correct vs 82.6% with UTD (p=0.06) and 84.9% vs 75.6% on case two (p=0.13). 

Conclusion
The awareness of imagining resources among first year medical students is generally low. Following a case presentation, students more strongly agreed that UTD is a more helpful resource in establishing a differential diagnosis. However, students found that ACR was easier to use to determine the appropriate imaging modality. The results also showed a trend towards significance with students making more accurate decisions utilizing ACR over UTD.

Comparing ACR Appropriateness Criteria and UpToDate in Medical Student Radiology Decision Making

Introduction
While the proportion of women in surgery has grown, more than 90% of practicing cardiothoracic surgeons are men. The 2010s and early 2020s have witnessed a heightened awareness of gender disparity, with increased focus placed on career mentorship. We sought to examine the current landscape of female representation at different points along the cardiothoracic surgery training and career path.

Methods
Medical student, resident, and active practice surgeon demographics were obtained from the AAMC. We identified five major U.S. cardiothoracic surgical societies, noting members of all committees. Gender was probabilistically determined using Gender Guesser (NamSsor SAC LLC, France), a commercially available artificial intelligence tool.

Results
We identified 456 individuals occupying both junior and senior level committee positions across five major US cardiothoracic surgical societies. Of committee members, 78 (26%) were identified as likely female. Among committee chairs and executive leadership boards, 48 individuals (31%) were likely female. Gender probability ranged from​​ 0.52-0.99 across the cohort, with average probability of 0.95. Female ACGME thoracic surgery residents represented 29.5% of the incoming class in 2023. Comparatively, women were noted to account for only 8.3% of active thoracic surgeons. Across a composite of ACS recognized surgical subspecialties with AAMC data (General, Neurological, Orthopedic, Plastic, Thoracic and Vascular, Obstetrics and Gynecology, Ophthalmology, Otolaryngology, Urology, Sports Medicine (Orthopedic Surgery)) women accounted for 29.1% of all practicing surgeons in the US.

Conclusion

While gender distribution in cardiothoracic surgery shows balance at early career stages, current practice remains skewed. Despite this, women are present and active at junior and senior levels within major cardiothoracic societies. The presence of women in leadership roles from which they may provide mentorship and guidance may be positively influencing career choices of trainees.


Gender Trends in Cardiothoracic Surgery: Examining Female Participation in Training, Practice, and Leadership Roles

Medical students' involvement in research is crucial for their professional development, yet challenges often hinder their access to meaningful opportunities. Mentorship and connection with research personnel enhance student research involvement, but facilitating these connections poses a common obstacle for students.
A committee comprising six medical students and four faculty advisors created a cutting-edge Microsoft database, compiling contact details, areas of expertise, and projects of researchers open to mentoring medical students. This platform serves as a bridge, connecting faculty needing research assistance with students seeking experience. Powered through the Microsoft Universe, it empowers students to select mentors aligned with their objectives and skills.
The committee also crafted student researcher online profiles, illuminating the pathways of success for underclassmen. Moreover, in-person mentorship sessions led by upperclassmen became hubs of knowledge exchange by imparting research skills and insider insight.
Emphasizing continuous improvement, the committee embraced feedback loops and surveys, including collaborative efforts with faculty-administered surveys, to capture the nuanced perspectives of students on the accessibility of research.
The creation of a Microsoft database, mentorship sessions, and student researcher profiles has generated a catalog of over fifty established researchers eager to mentor students. A list of 45 projects across six different departments has been compiled, each spearheaded by a faculty member who is ready to invest in student success. Three student-led mentorship sessions have been held, covering topics such as research methodology and its impact on specialty choice, with plans to continue events monthly. Surveys indicated all attendees found the events beneficial and hoped to attend more. Additionally, nearly 20 student researcher profiles have been published on an institution-associated website, promoting collaboration and transparency. Profiles include contact details, enabling other students to have increased approaches to research-based networking and knowledge.
Three avenues, a Microsoft Universe powered database, student-led mentorship sessions, and student research profiles, each offer a unique route of mentorship that together make medical student research easier to navigate. The database distinctly connects students and faculty, fostering long-lasting relationships with added faculty expertise. Mentorship sessions allow upperclassmen to disburse insight to a large group, while student profiles promote one-on-one mentorship, encouraging conversation and tailored collaboration. Together, these three cornerstones, each offering a unique form of mentorship, synchronize to create a strong foundation for medical students to navigate and succeed in research.


A Student-Led Database and Mentorship Model for Facilitating High Quality Research

Background
Biostatistics is an increasing focus in current medical school curricula, even appearing as a topic on the United States Medical Licensing Exam Steps 1, 2, and 3 (USMLE). Physicians already in practice who did not have the benefit of biostatistics training in medical school likely can benefit from clarification and instruction of statistical methods. The goal of the study is to document and evaluate statistical methods utilized in a high-impact factor Journal, then to develop a guide to those statistics that can be applied to facilitate the interpretation of statistics for practicing physicians, fellows, residents, and medical students. 

Methods 
In Part I of our tandem manuscripts, the 100 most recent primary articles, dating from February 2021 to December 2021, were extracted and analyzed from the Journal of Intensive Care Medicine. The evaluation consisted of study temporality, study design, types of descriptor variables, and types of statistical tests. Statistical analyses was conducted using the Fisher’s Exact test with p-values <0.05 considered statistically significant.

Results
Retrospective studies were most common (75/100, 75%), followed by prospective (23/100, 23%), and cross-sectional studies (2/100, 2%). The most popular designs were cohort (82/100, 82%), followed by case series (9/100, 9%), randomized control trials (4/100, 4%), and case-control (3/100, 3%). The most commonly utilized descriptor variables were frequency and proportion (100/100, 100%), followed by both median (74/100, 74%), average (71/100, 71%), and interquartile range (68/100, 68%). The chi-square test was the most frequently used statistical test (59/100, 59%), while logistic regression (48/100, 48%), Mann-Whitney-U (46/100, 46%), and two-sample independent t-test (40/100, 40%) also were popular. A subgroup analysis of cohort studies showed higher use of the chi-square test (44/63, 70% vs 8/19, 42%; p = 0.03) and logistic regression (40/63, 63% vs 5/19, 26%; p = 0.008) in retrospective compared to prospective studies.

Conclusion 
This review of statistics used in 100 primary journal articles revealed that retrospective and cohort studies were utilized most frequently. The chi-square test was used in the majority of studies, particularly in retrospective cohort studies. This information can help determine areas in which supplemental training will be most beneficial to improve the understanding of statistical methods in medical journals by practicing physicians, fellows, residents, and students. As an outgrowth of this study, we have developed a practical guide to relevant statistical methods serving as part 2 of this double manuscript, and plan to conduct a larger study based on this methodology.

Analysis of Statistics Utilized in Primary Articles in the Journal of Intensive Care Medicine: A Prelude to Practical Pedagogy in Biostatistics

Abstract Title:
Addressing Training for Medical Students to Cope with Traumatic Situations
Background:
‘Second victim phenomenon’ refers to feelings of guilt or failure following an unanticipated outcome or error. This phenomenon is prevalent in the medical field, with some articles stating that over half of healthcare workers experience a ‘second victim phenomenon’ at least once in their career.
Within medical school curriculums, students learn to identify many diseases and disorders. Despite this extensive coverage, there remains a significant gap in preparing medical students for the inevitable trauma they will face as physicians. 
Methods:
A systematic literature review was performed. Informal and small group discussions from professional meetings were conducted. We then created an IRB-approved survey to send to medical students of all four years at six MD/DO schools throughout Virginia. The survey is open for two weeks and includes questions that ask how prepared students feel to cope with traumatic events, whether their school currently has a curriculum that teaches healthy coping mechanisms, and whether they believe a formal curriculum should be implemented.
Results:
Our preliminary data revealed 86.1% of 2287 newly graduated residents in 2015 reported feeling comfortable presenting physical exams, and 92.3% felt prepared to take patient histories. Only 46.3% of these residents felt prepared to cope with death, and only 34.1% felt capable of managing their fatigue. In a 2019 study, 534 internal medicine residents were surveyed. 90% reported that they had never heard of ‘second victim phenomenon’ prior to the study. After learning what it was, 59% of these residents reported experiencing at least one or multiple ‘second victim’ events during their careers. 12% (n=287) either required more than a year to recover or never recovered.
At a professional meeting in April 2024, several topic experts agreed that a curriculum is necessary, and one resident agreed that he and his colleagues have experienced ‘second victim phenomenon.’
Preliminary data from our survey is showing that 95.7% of medical students voted to include educational resources on healthy coping mechanisms during their time in school, with 60.9% of these students responding that they would prefer a mandatory course.
Conclusion:
This study aims to not only bring awareness to mental health challenges associated with a career in medicine but to also work with topic experts to implement a curriculum within medical schools. Addressing this issue is crucial, as the well-being of physicians directly impacts patient care. Providing students with a curriculum is a strong step forward in preparing physicians for the psychological demands of this profession.

Are You Ready For It? A Call For A Second Victim Phenomenon Training

Background
The spread of pathogens poses a significant threat to public health, but strategies like herd immunity and social distancing can mitigate this risk. Despite the well-documented benefits of these strategies, their effectiveness hinges on widespread public adherence and understanding. Recent events, such as the SARS-CoV-2 pandemic, have underscored the challenges posed by public resistance and misinformation. Studies have highlighted increased skepticism and misinformation regarding vaccination, undermining herd immunity efforts. To address this growing need for resources to counter doubts about public health decisions, we sought to develop software using cellular automaton models that can not only educate individuals on the value of practices like social distancing and vaccinations on disease spread, but also showcase realistic results to improve understanding.
Methods
We developed a simulation tool using a discrete cellular automaton process, modeling disease spread through a population grid where individuals can change states (susceptible, infected, vaccinated). Users can input parameters such as disease transmissibility, vaccination rates, and social distancing protocols to simulate scenarios across time. This model was tested as an educational supplement in an immunology class. Additionally, we developed a probabilistic multi-state cellular automaton model, incorporating stochastic elements to reflect randomness in disease transmission and individual behaviors. We applied the model to real-world data from COVID-19 databases to evaluate the effectiveness of herd immunity and social distancing in different communities.
Results
A survey of students using the discrete simulation found 83% reporting the software was intuitive, while 100% felt it increased understanding of herd immunity. The probabilistic cellular automaton model illustrated the positive impact of vaccination and social distancing on herd immunity, demonstrating vaccine effectiveness can be nearly 650 times more effective when social distancing is enforced. Additionally, the simulations revealed emerging patterns, such as regions without disease spread, possibly informing new metrics for evaluating public health responses.
Conclusion
Overall, this probabilistic simulation can serve as a valuable epidemiological tool to help characterize public health conditions. Furthermore, this simulation can be used as an educational tool for the public to better understand the mechanisms of herd immunity and the impact of their own behavior on disease spread. Future improvements to this model can include consideration of state transition adjustments, external system shocks, and additional considerations to initial conditions. The simulation tool's user-friendly interface and adaptable parameters make it feasible for widespread educational use, especially in unprecedented times. Its generalizability extends to various public health scenarios, promoting broader understanding of epidemiological strategies.

Characterizing Herd Immunity Through Cellular Automaton Models

Background: The hospital environment is a complex and unpredictable workplace where different providers share the responsibility of patient care. Differences in opinions, values, and experiences between resident physicians and other care team members may trigger conflicts that affect the safety and quality of patient care. Thus, developing conflict competencies may help to negotiate the complexities of different conflict situations and resolve these conflicts. However, the extent of the knowledge and perception of conflict competence among resident physicians remains to be determined.

Methods: A survey and qualitative semi-structured interviews of resident physicians were conducted. Participants were recruited voluntarily. Survey results were analyzed using SPSS 21, and MAXQDA 24 was used to evaluate the interview transcripts with thematic analysis.

Results: Sixty-five resident physicians completed the survey, and fifteen resident physicians were interviewed. 61.5% of the survey respondents identified as female, 76.9% were Caucasian, 35.4% of the respondents were from surgical specialties, and
43.1% of the residents were in their second year of training.
53.8% of the participants reported witnessing or experiencing conflicts weekly, with 44.6% reporting resident physician-nurse conflicts. 63.1% of the conflicts were reported as unresolved, with 16.9% reporting that the conflict affected future working relationships, 25.5% of the conflicts were due to failure of communication, 75.4%residents did not have any form of prior training on conflict management, and 83.1% of them reported interest in conflict competence training. Conflicts mainly affected the quality of care (87.3%) compared to patient safety concerns (12.3%). Participants with prior training in conflict competence were more likely to resolve their reported conflict (p= .047). The interviews highlighted five main themes: sources of conflict, awareness of conflict resolution styles, addressing conflict and outcomes, and the effect on patient care. Sources of conflict included hierarchy and different priorities. 52.2% of the respondents did not know any style of conflict resolution.
Addressing conflict included collaboration, avoidance, competition, and prevention. Avoidance was the most common style used by interviewees, followed by collaboration. While most felt that the conflicts affected the quality of patient care, one interviewee reported severe adverse events on the patient.
Conclusion
Conflicts are rife in the hospital environment and can affect patient care when unresolved. Resident physicians' knowledge of conflict competence is low and does not reflect the complexity of their working environment. Future training in conflict competence and resolution is warranted.

Keywords: conflict, conflict competence, resident physicians, hospitals


Conflict competence among resident physicians: knowledge and perception

Background
Inclusive sexual history training in medical education is crucial for addressing the health needs of LGBTQ+ patients. Literature indicates many physicians feel inadequately trained on LGBTQ+ health needs, exacerbating healthcare disparities. This study evaluates the impact of a structured training program on medical students’ ability to take sexual histories from LGBTQ+ patients effectively.

Methods
A two-hour educational session led by Dr. Shira Heisler, medical director of the Detroit Public Health STD clinic, was presented to 36 Wayne State University School of Medicine students. During this session, students learned how to take a comprehensive sexual history and practiced with peers via role-playing exercises. Participants were recruited via email and received volunteering credit for attendance. Data was collected through pre-session and post-session surveys using a 10-point Likert scale to measure students’ experiences, knowledge, and attitudes. These surveys were intended to highlight gaps in LGBTQ+ sexual history training and evaluate the session’s effectiveness.

Results
Overall, there was a significant increase in students’ comfort interacting with LGBTQ+ patients post-session (p-value = 0.00019). Students’ rating of the importance of taking an LGBTQ+-inclusive sexual history also significantly increased post-session (p-value = 0.00066). First-year medical students demonstrated a statistically significant increase in comfort with taking a sexual history of patients who exclusively have sex with opposite-gender partners (p-value = 0.0015) as well as patients who have sex with partners of the same or multiple genders post-session (p-value = 0.00092), while second-year students did not demonstrate a significant difference post-session for either category.

Conclusion
By addressing medical education gaps in LGBTQ+ health, this session aimed to improve LGBTQ+ community healthcare outcomes. The data collected suggests that attending inclusive sexual history-taking education sessions effectively improves students’ comfort with taking a sexual history for both LGBTQ+ and non-LGBTQ+ patients. Ultimately, fostering an inclusive approach to sexual history-taking can contribute to more equitable healthcare.

Cultivating confidence: improving LGBTQ+-focused sexual history training for medical students​

Background
Effective communication in challenging patient interactions is crucial in medicine. While simulation labs are ideal for training, they lack universal accessibility. AI-based patient encounters provide an innovative tool for medical education that allow students to test new communication methods in a risk-free environment. We present an integrated educational module with best practice videos and an AI-based simulation app for honing skills in delivering difficult news to patients.

Methods 
The educational component includes videos on best practices for delivering bad news, followed by interactive training using an AI-powered app based on a Large-Language Model, programmed in Python. To build the AI simulation modules, a pilot case prompt was first created by specifying the clinical scenario and patient personality in ChatGPT-4o. This prompt was further refined to an appropriate length and personality specifications using an iterative prompting process within ChatGPT-4o. After testing this case in the app environment, multiple cases were designed using standardized prompts based on the pilot case specifying diagnoses, communication styles, and personality traits based on the Big Five model. The AI app incorporates diverse clinical scenarios presenting challenging situations and difficult conversations and provides personalized feedback based on the SPIKES protocol.

App Development 
The AI-powered app was developed to simulate realistic patient interactions. The OpenAI API was employed to generate patient responses and emotional cues using ChatGPT-4o from predefined cases. Each case includes a multidimensional prompt architecture, enabling the AI to portray various clinical scenarios and patient personalities accurately. A separate AI agent evaluates student performance using the SPIKES model criteria and provides real-time formative feedback on communication techniques.

Results 
The AI patient actors demonstrated accurate personality embodiments and significant emotional responses. In addition to giving appropriate responses, the app also provided body language and contextualizing statements in line with the encoded personality before beginning dialogue such as “fidgets nervously” or “takes a deep breath, trying to calm down.” The app assessed student performance against the SPIKES protocol and generated constructive feedback. The AI Patient Actor app for difficult conversations is openly available at https://patient-actor-dc.streamlit.app/.

Conclusion 
This fully integrated educational module, combining best practice videos and an AI simulation app, is an innovative tool for communication skills training that can provide formative skills training at scale. The module will be incorporated into Dartmouth's Geisel School of Medicine curriculum. Validation through cohort testing will follow.

Difficult conversations skills training using an AI-based patient actor app

Artificial intelligence (AI) has significant potential in medicine, especially in diagnostics and education. ChatGPT has achieved levels comparable to medical students on text-based USMLE questions, yet there's a gap in its evaluation on image-based questions. This study evaluated ChatGPT-4's performance on image-based questions from USMLE Step 1, Step 2, and Step 3. The overall performance of ChatGPT-4 on USMLE Steps 1, 2, and 3 was evaluated using 376 questions, including 54 with images. The accuracy was 85.7% for Step 1, 92.5% for Step 2, and 86.9% for Step 3. For image-based questions, the accuracy was 70.8% for Step 1, 92.9% for Step 2, and 62.5% for Step 3. In contrast, text-based questions showed higher accuracy: 89.5% for Step 1, 92.5% for Step 2, and 90.1% for Step 3. Performance dropped significantly for difficult image-based questions in Steps 1 and 3 (p=0.0196 and p=0.0020 respectively), but not in Step 2 (p=0.9574). Despite these challenges, the AI's accuracy on image-based questions exceeded the passing rate for all three exams. ChatGPT-4 can handle image-based USMLE questions above the passing rate, showing promise for its use in medical education and diagnostics. Further development is needed to improve its direct image processing capabilities and overall performance.

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