United States

Abstract Title

Paraneoplastic Hypercalcemia as the Initial Presentation of Hepatocellular Carcinoma in a Patient with Alcoholic Cirrhosis
Authors :
Isha Gupta , MD Muhammad Usman , MD
Mayur Ravjibhai Kaklotar , MBBS Suriya Shan , MD

Background

Hypercalcemia is a serious metabolic disturbance that can serve as a paraneoplastic manifestation of malignancy. While commonly associated with squamous cell, renal, and breast cancers, hypercalcemia in hepatocellular carcinoma (HCC) is rare but clinically important. One key mechanism is PTH-related peptide (PTHrP)-mediated hypercalcemia, where tumor cells secrete PTHrP, mimicking parathyroid hormone and causing increased bone resorption and renal calcium retention.

In patients with cirrhosis or other chronic liver diseases, symptoms such as fatigue or weakness are often nonspecific and attributed to hepatic dysfunction. However, the presence of unexplained hypercalcemia, especially without bone metastases or supplement use, should prompt evaluation for an underlying malignancy. Though uncommon, PTHrP-producing HCC can be the initial presentation of liver cancer.
Recognizing this paraneoplastic syndrome is essential for timely diagnosis and management, particularly in patients with known risk factors such as alcohol-related cirrhosis.


Case Presentation

A 55-year-old male with hypertension, hyperlipidemia, type 2 diabetes, and a history of heavy alcohol use (abstinent for three years) presented with progressive weakness over two weeks. Initial labs showed marked hypercalcemia (15.6 mg/dL) without supplement use. He was treated with intravenous fluids and calcitonin, reducing calcium to 10.3 mg/dL. Additional labs revealed elevated AST and ALP, hypoalbuminemia (2.5 g/dL), and mild anemia. Viral hepatitis markers were negative. A pan-CT showed no evidence of metastases. MRI abdomen revealed cirrhosis with multiple LIRADS-5 lesions showing arterial enhancement with washout, suggestive of hepatocellular carcinoma (HCC). Bone scan was negative for metastases. PTH-related peptide

was elevated (6.0 pmol/L) with a non-elevated intact PTH, consistent with humoral hypercalcemia of malignancy. The final diagnosis was PTHrP-mediated paraneoplastic hypercalcemia secondary to HCC in the setting of cirrhosis. The patient was discharged after stabilisation and advised to follow up with oncology for further evaluation and management.


Discussion

Hypercalcemia is rare in compensated cirrhosis, but when present without a clear cause, it may indicate an underlying malignancy such as hepatocellular carcinoma (HCC). In fewer than 5% of HCC cases, paraneoplastic hypercalcemia occurs due to PTHrP secretion. Routine calcium monitoring in patients with heavy alcohol use may aid in early detection of serious complications like HCC.

References : 
1. Hu MI, Glezerman IG, Leboulleux S, Insogna K, Gucalp R, Misiorowski W. Advanced therapies for hypercalcemia of malignancy. Front Endocrinol (Lausanne). 2023;14:1039490. doi:10.3389/fendo.2023.1039490
2. Alameri HF, Abdel-Rahman ME, Guturu P. Humoral hypercalcemia of malignancy as a presenting manifestation of hepatocellular carcinoma: a case report and literature review. HPB (Oxford). 2024;26(9):1321-1324. doi:10.1016/j.hpb.2024.06.009
3. Chen S, Li J, Zhang J, et al. Paraneoplastic syndromes in hepatocellular carcinoma: recent advances and clinical implications. World J Clin Cases. 2024;12(5):856-867. doi:10.12998/wjcc.v12.i5.856
4. Rahman M, Alqahtani S, Farghaly M, et al. Paraneoplastic hypercalcemia due to hepatocellular carcinoma: a case report and review of the literature. Cureus. 2022;14(4):e23978. doi:10.7759/cureus.23978
5. Mirrakhimov AE. Hypercalcemia of malignancy: an update on pathogenesis and management. J Clin Endocrinol Metab. 2015;100(5):2024-2034. doi:10.1210/jc.2015-100


AMA Research Challenge 2025 

Paraneoplastic Hypercalcemia as the Initial Presentation of Hepatocellular Carcinoma ina Patient with Alcoholic Cirrhosis

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Background
Chronic pain poses numerous challenges and is likely sustained by long-term changes in the nervous system. Central sensitization (characterized by pain pathways in the central nervous system (CNS) becoming hyperresponsive) is prominent in such chronic conditions. Though the etiology of many chronic pain conditions are traceable to injurious events or diseases, some conditions still rely on a diagnosis by exclusion as there is no single test to confirm the condition. One such condition is interstitial cystitis or bladder pain syndrome (IC/BPS). Symptoms include intense pelvic pain, sudden strong urges to micturate, and pain relieved upon
voiding the bladder. Though initially considered a periphery-specific painful condition, in its chronic stage, changes in the CNS can also play an important role and may involve neuroinflammation states.
Methods
We utilized a Vascular Endothelial Growth Factor A (VEGFA) murine IC model, in which mouse bladder instillation of VEGFA has been established to reproduce clinical BPS-associated pathological and behavioral changes. The BPS group underwent 3x intravesical installations with VEGFA once every other day while controls received 3x saline. Pain behavior was assessed via abdominal von Frey and Mouse Grimace Scale at baseline, 24 hrs., 3, and 7 days post-final installation. Brain tissues were collected at 3 days and stained for activated astrocytes (GFAP) and microglia (IBA1).
Results
VEGF-treated mice exhibited clear mechanical and spontaneous pain persisting at least 1 week post treatment, confirming a prolonged pain state. Increased astrocytic and microglial activations were also observed. Together, this suggests that an interplay between a peripheral-derived disease and its associated CNS changes contribute to the persistent pain state, in which neuroinflammation may play an important role.
Conclusion
Our findings support the emerging theory of activity-dependent neuroinflammation:
hypothesizing that persistent peripheral input induces brain neuroimmune activations, which contributes to central sensitization. While central sensitization in BPS is recognized, this study is among the first to show direct evidence of BPS inducing brain glial activations. Activated microglia amplify excitation and hypersensitivity by releasing mediators such as pro-inflammatory cytokines and reactive oxygen species. Excessive astrocytic activation can also disrupt glutamate homeostasis, secreting cytokines and chemokines that heighten neural activity. This study reinforces the broader view of chronic pain as a circuit-wide disorder, challenging the assumption that localized symptoms require only localized treatments. Future work in our lab is exploring glial pathway modulation to disrupt this circuit, with implications for both organ-based and CNS-driven syndromes.

Visceral Pain Induces Central Glial Activation: Evidence from a Murine Bladder Pain Model

Background: Intervertebral disc (IVD) degeneration (IDD) is the leading cause of low back pain, affecting 25% of U.S. adults in any 3-month period and nearly 40 million workers. 40% of individuals over age 40 and 80-90% by age 80 exhibit IDD. Low back and neck pain lead U.S. healthcare spending among 154 conditions, totaling $134.5 billion annually. Although early nucleus pulposus (NP) degeneration is critical for diagnosis and treatment, it is often missed on standard Magnetic Resonance Imaging (MRI). Micro-computed tomography (micro-CT) offers excellent three-dimensional (3D) bone visualization but lacks soft tissue contrast to visualize the IVD. While contrast-enhanced micro-CT has been investigated, an effective contrast agent for IVD has not been identified. This study investigates potassium iodide (KI) as an effective contrast agent for micro-CT-based IVD visualization across multiple animal models to study IDD. 

Methods: We harvested spines and tails from skeletally matured mice, rats, rabbits, and sheep, incubated in 25% aqueous KI solution, and scanned using micro-CT (Sky Scan 1273) with a resolution of 10 μm. To evaluate KI in IDD, we performed caudal IVD annular puncture on 12-week-old mice (n=10) using a 30-gauge needle, with adjacent IVDs as sham control. Tails were collected two weeks post-surgery. For the aging model, we compared IVDs from 18–21-month mice (n=5) to 3-month controls (n=5) and validated our method on rabbit and sheep (n=5) IVDs. Micro-CT results were compared with histological data from the same sample. 

Results: Compared to unstained IVDs, KI-stained IVDs exhibited strong x-ray attenuation comparable to surrounding bone, enabling high-resolution 3D visualization of IVDs in all animal models. Quantitative measures such as IVD height and volume showed high reproducibility. KI staining of punctured IVDs showed significant reduction in IVD height, NP area, and volume versus sham controls (p=0.014), mirroring histological findings from the same samples. In aging spines, KI staining revealed varying degrees of degeneration in lumbar IVDs. After scanning, KI was removed by PBS wash for histology and immunostaining, with no additional antigen retrieval step required. 

Conclusion: This preclinical study presents KI as a rapid, reversible, non-destructive, histologically-compatible, and accessible contrast agent for detailed micro-CT IVD imaging. It clearly identifies degenerative changes across species and models, is significantly faster (<1 hr) than previously published methods (>24 hr to 2 months), uses FDA-approved KI, and standard micro-CT scanners. Clinical development of this method could substantially reduce delays in MRI access and diagnostic imaging.

A Rapid, Non-Destructive, Specific Method for Intervertebral Disc Imaging With KI-Enhanced Micro-CT

Background
Acute kidney injury (AKI) is a common and life-threatening complication of sepsis, yet early, non-invasive detection of tubular dysfunction remains challenging. Resazurin, a redox-sensitive dye traditionally used in cell viability assays, has emerged as a novel in vivo biosensor of renal tubular function. Following systemic administration, resazurin is taken up by proximal tubular epithelial cells, where it is enzymatically reduced to the fluorescent compound resorufin. Urinary resorufin levels reflect mitochondrial metabolic activity and serve as a functional readout of tubular health. In prior murine models of AKI such as cisplatin and ischemic reperfusion injury, diminished resorufin signal correlated with worse histologic injury and elevations in conventional biomarkers such as blood urea nitrogen (BUN) and creatinine.
Methods
We are evaluating resazurin in two murine models of sepsis-induced AKI: (1) cecal ligation and perforation (CLP), a surgical model inducing polymicrobial sepsis, and (2) lipopolysaccharide (LPS) injection, which triggers endotoxemia via systemic inflammation. Mice received intravenous resazurin, and urinary fluorescence of resorufin was measured at defined intervals. Renal function was concurrently assessed using BUN, creatinine, and histopathology.
Results
Preliminary findings show that both CLP and LPS models produce consistent and comparable patterns of renal tubular dysfunction. In both models, a marked decline in urinary resorufin levels was observed early, preceding significant elevations in BUN and creatinine. Histological analysis confirmed tubular injury in parallel with reduced metabolic activity detected via resazurin imaging. These results validate resazurin as a sensitive and non-invasive reporter of early tubular dysfunction in inflammatory kidney injury.
Conclusion
Resazurin offers a rapid, non-invasive, and translationally promising approach for real-time monitoring of renal tubular function. Its application in sepsis models highlights its potential as a functional biomarker for early AKI detection, with broad utility for preclinical and future clinical research.


Utilizing Resazurin Dye to Detect Kidney Dysfunction in Sepsis

Introduction: 
An estimated 1.5 million people in the U.S. are living with, or in remission from, a hematological malignancy (HM). Many of these individuals are particularly vulnerable to infections such as COVID-19, influenza, and pneumococcal disease. Immunocompromised patients often experience more severe illness, prolonged disease, higher rates of ICU admission, and death. Vaccination remains a key strategy for reducing these adverse outcomes. The aim of this study was to assess vaccination rates and identify modifiable factors associated with COVID-19, influenza, and pneumococcal vaccinations in HM survivors.
Methods: 
We conducted a cross-sectional analysis of data from the 2022 and 2023 CDC Behavioral Risk Factor Surveillance System-Cancer Survivorship Optional Module. Population-based vaccination estimates and 95% CIs were calculated. All statistical tests were 2-sided with p < .05 was considered significant.
Results: 
Of the 1,335 HM survivors, 56.8% had lymphoma, 29.7% had leukemia, and 13.5% had other blood malignancies. The vaccination rates for COVID-19, influenza, and pneumococcal were 46.0%, 57.7%, and 57.4%, respectively. Influenza vaccination was associated with having had an annual physical exam (p = .000), having CVD (p = .003), diabetes (p = .034), not being a current smoker (p = .001), and having 3+ comorbidities (p = .001). Pneumococcal vaccination was associated with having had an annual physical exam (p = .019), receiving follow-up instructions from a doctor after completing HM treatment (p = .020), having COPD (p = .000), CVD (p = .000), diabetes (p = .001), CKD (p = .029), not being a current smoker (p = .003), and having 3+ comorbidities (p = .019). Older age (65+) is associated with higher rates of both influenza and pneumococcal vaccinations. No variable significantly predicted COVID-19 vaccination. Vaccination rates did not vary by type of HM. 18.9% of patients did not receive follow-up instructions from their doctor after completing cancer treatment, and only 10.9% reported participating in a clinical trial as part of their cancer care.
Conclusions:
We identified several modifiable factors, underreported in the literature, that are associated with non-vaccination. Improving awareness among both physicians and patients may help increase vaccination rates and enhance protection for this at-risk population.

Factors Associated with COVID-19, Influenza, and Pneumococcal Vaccination in survivors of Hematologic Malignancies

Background: Efforts to expand patient portal use across the country, while well-intentioned, may inadvertently widen health inequities by failing to address the distinct challenges faced by marginalized populations. Safety-net clinics, which serve those most at risk for health disparities, continue to report low portal adoption, suggesting that drivers of engagement differ fundamentally from national trends. This mixed-methods study wants to moves beyond documenting disparities and instead identify context-specific patient profiles that explain barriers to portal adoption. We aimed to (1) identify distinct patient subgroups influenced by local barriers using clustering analysis, (2) use qualitative data to characterize these profiles, and (3) evaluate whether national models adequately predict portal use in this context. 
Methods: We conducted a cross-sectional, mixed-methods study at a student-run free clinic that primarily serves Spanish-speaking, uninsured Latine patients. A total of 112 patients completed surveys assessing portal use and confidence in managing health information, and 42 providers shared perspectives on implementation. Patient profiles were identified using K-means clustering, and 11 semi-structured interviews added nuance and context from patient voices. To assess generalizability, findings were compared with national data from the Health Information National Trends Survey (HINTS6; n=6,252).
Results: Portal adoption in our clinic was 22.3%, less than half the national rate of 58%. Our primary analysis identified four distinct patient profiles: “Healthcare Engaged” (high confidence, high use), “Digitally Disengaged” (low confidence, low use), “Information Access Challenged” (engaged but struggling with usability), and “System Navigators” (moderately engaged). Qualitative interviews highlighted that engagement patterns were shaped primarily by usability challenges and trust, not by deficits in health literacy. A predictive model based on local behavioral data performed no better than chance (Area Under the Curve [AUC] = 0.47). In contrast, the same model applied to national HINTS6 data was highly predictive (AUC = 0.93), underscoring that drivers of portal use locally are fundamentally different.
Conclusion: Patient portal adoption in safety-net settings is shaped by local barriers, especially those related to usability and trust, that are not captured by national datasets. Our findings illustrate how models built on national predictors, though effective at the population level, may fail to account for the specific challenges faced by underserved communities. By identifying distinct patient subgroups through mixed-methods analysis, we provide a practical framework that healthcare organizations can use to design more equitable and targeted digital health strategies.

Patient Portal Adoption in Underserved Communities: A Mixed-Methods Study

Background
The American Society of Hematology, through the Choosing Wisely campaign, advises against inpatient thrombophilia testing for adult patients with acute thrombotic events. In this setting, hypercoagulable panels frequently yield false-positive results and rarely influence immediate management. An exception can be made for patients with high clinical suspicion for antiphospholipid syndrome (APS), such as those with recurrent pregnancy loss or underlying autoimmune disease, where test results may change anticoagulation decisions to the use of warfarin. Despite these guidelines, inappropriate testing remains common. This study examines the utilization of inpatient thrombophilia testing and associated financial costs in a quaternary care hospital.

Methods
We conducted a retrospective review of adult inpatients admitted between July 1, 2022, and June 30, 2024, with one of the following ICD-10 codes: I81 (portal vein thrombosis), I82 (other venous embolism and thrombosis), I26 (pulmonary embolism), I74 (arterial embolism and thrombosis), and I63 (cerebral infarction). Patients with arterial thrombosis secondary to myocardial infarction were excluded. Demographic variables included age, sex, smoking status, contraceptive use, and active cancer diagnosis. Antiphospholipid antibody testing included beta-2 glycoprotein antibodies, cardiolipin antibodies, dilute Russell’s viper venom time, hexagonal phase phospholipid antibody, and phosphatidylserine antibodies. Inherited thrombophilia testing included antithrombin antigen and activity, protein C and S activity, Factor V Leiden, prothrombin gene mutation and activated protein C resistance. Additional testing included JAK2 mutation analysis, calreticulin mutation analysis, and paroxysmal nocturnal hemoglobinuria flow cytometry. Cost analysis was performed using MATLAB.

Results
Among 2,287 hospitalizations meeting inclusion criteria, 271 patient encounters involved thrombophilia testing. Of those tested, 137 were female and 134 were male. Fifty-three patients were active smokers, 18 had an active cancer diagnosis, and 10 were receiving estrogen therapy. Fifty-one patient encounters met accepted criteria for testing in the setting of arterial thrombosis in patients under age 50. In contrast, 78 patients underwent testing that did not meet these criteria. Other patients meeting criteria include seven patients with thrombosis in unusual locations (portal vein or cerebral venous sinuses), and five with recurrent venous thromboembolism. The estimated cost of appropriately indicated testing was $9,416, while inappropriate testing accounted for $92,090.

Conclusion
These findings highlight significant overuse of inpatient thrombophilia testing, resulting in unnecessary healthcare costs. As a quality improvement initiative, our institution plans to restrict ordering of inpatient inherited thrombophilia testing to providers affiliated with the hematology department. This targeted intervention supports efforts to increase high-value care and promote guideline-concordant practice.


Retrospective Review of Inpatient Thrombophilia Testing in a Tertiary Hospital, 2022–2024

Impact of an Anatomy Lab-based Workshop on Preclinical Medical Student Interest
Background

There is a significant global shortage of neurologists. With an aging population and increasing prevalence of neurological disorders, the consequences of this shortage are expected to worsen, including reduced access to care and increased physician workload. Medical students are not always required to complete a neurology clerkship prior to applying for residency, so early preclinical exposure is critical to promoting interest in neurology. Since preclinical students are often given minimal interactive experience with neurology, students rely on extracurricular interest group-led activities to generate and gauge interest. Educational workshops focused on neurological procedures can provide preclinical students with hands-on exposure to neurology and facilitate early interest in the specialty to help address the physician shortage in the long-term.

Methods
Thirty preclinical students at the University of Central Florida College of Medicine took part in an anatomical donor-based workshop organized by the Student Interest Group in Neurology (SIGN) and Neurosurgery Interest Group (NSIG). The workshop consisted of a ventriculostomy simulation followed by group-led teaching of different neurological pathologies using post-mortem brain specimens. Surveys quantifying preclinical students’ interest in applying to neurology residency on a 5-point Likert scale were completed before and after the workshop. Changes in interest were analyzed using a two-tailed Wilcoxon signed-rank test for paired samples. Students also completed survey questions assessing how much they believe extracurricular opportunities shape their interest and knowledge of different specialty choices.

Results
Among the 30 preclinical students surveyed, the average interest in neurology on a five- point Likert scale showed a significant increase from 2.9 pre-workshop to 3.6 post- workshop (W=131.0, p = 0.0009). In a qualitative exit survey, students identified extracurricular activities as important in shaping their interest (3.8 ± 1.0) and knowledge (3.7 ± 1.2) of medical specialties.

Conclusion
We observed a significant increase in neurology interest among preclinical students after this anatomical donor-based workshop. Moreover, preclinical students reported that workshops like these are useful for learning about medical specialties in practice. Preclinical activities like this workshop could therefore help to address a worsening shortage of neurologists by promoting earlier exposure and interest in the field.

Impact of an Anatomy Lab-Based Workshop on Preclinical Medical Student Interest in Neurology


OBJECTIVE: Evaluate the subjective efficacy of a cadaveric nephrostomy access model for improving training and increasing educational opportunities for radiology residents interested in Interventional Radiology. 
DESIGN: A cadaveric torso was dissected and prepared in advance for the session, ensuring a realistic and effective learning environment. Residents interested in interventional radiology were recruited to participate in the simulation. Each resident was allotted 20 minutes to perform the nephrostomy tube access under ultrasound and fluoroscopy with the supervision of a certified interventional radiologist with 10 years of experience. The study included pre- and post-simulation surveys to evaluate the training's impact on various subjective outcomes. Participants rated their responses using a defined 1-5 scale in all surveys.
RESULTS: A total of seven residents participated, and the pre- and post- survey response rate was 100%. PGY 2-7 residents participated in the simulation. Regarding content validity, participants rated all aspects of the simulation as either a 4 or 5 on the 5-point scale. Respondents held a positive view of cadaver sessions and believed them to be useful for learning anatomy (mean = 5) and found that the experience boosted their confidence in ability to do the procedure (mean = 5). Furthermore, it was thought that the training session significantly improved skills (mean = 4.86), gave transferable skills for the IR suite (mean = 5), and was feasible to incorporate into further training programs (mean = 5). 
CONCLUSIONS: This study on cadaveric simulation training demonstrated content validity. It also showed feasibility, acceptability, a high value for educational influence and cost-effectiveness for cadaveric simulation. 


Simulation Based Education in IR: A Cadaveric Model for Nephrostomy Tube Insertion

Abstract Title
Addressing North Lawndale’s HIV Disparities: An Inequality-Based Public Health Disaster
Background
Major discrepancies still exist in historically marginalized areas despite national progress in HIV prevention and treatment. A primarily Black neighborhood on Chicago's West Side, North Lawndale has one of the highest rates of new infection with HIV and prevalence in the city. This study investigates how HIV disparities in North Lawndale are impacted by systemic racism, social variables of health, and systematic policy neglect. It looks at how barriers to prevention and treatment, such as the use of pre-exposure prophylaxis (PrEP) and linkage to antiretroviral medicine, are shaped by uneasy housing, economic hardship, and healthcare inaccessibility.
Methods
Using a multidisciplinary public health framework, this research integrates
epidemiological data, policy analysis, and community health profiles to assess how historical disinvestment and stigma exacerbate HIV outcomes.
Results
Findings reveal that North Lawndale's HIV prevalence (842.1 per 100,000) and new
diagnoses (74.7 per 100,000) far exceed city averages, underscoring the urgency for
equity-centered intervention. Additionally, the neighborhood reports higher rates of mental distress and lower levels of educational attainment and economic opportunity—factors that directly influence health-seeking behavior and treatment adherence.
Conclusion
The research suggests a three-pronged public health strategy to tackle these disparities: boosting spending on anti-stigma education and policy advocacy; enhancing community-led HIV testing and care linkage initiatives; and increasing access to PrEP through pharmacy-based strategies. The recommended therapies place an emphasis on providing care that is culturally appropriate and fostering confidence in the community, and they are patterned after scientific methods from places like New York and San Francisco. 
This study comes to the conclusion that a strategic policy change from individual-focused care to systemic transformation is necessary to lower the prevalence of HIV in North Lawndale. The results highlight the necessity of broad approaches that take eliminated people' social reality into account. Future public health policies on HIV prevention in impoverished urban areas can be influenced by the execution of such focused policies, which can promote equitable health outcomes.

Addressing North Lawndale’s HIV Disparities: An Inequality-Based Public Health Disaster

Introduction 
As the USMLE Step 1 exam transitioned to pass/fail, narrative assessments have become an increasingly important factor in differentiating residency candidates. Studies have consistently shown that narrative assessments often contain bias that disproportionately affect students from underrepresented backgrounds. These narrative assessments may impact competitiveness for residency positions and limit career opportunities. Few faculty development resources exist to help recognize and mitigate bias. This project aims to implement a faculty development workshop on improving the quality of narrative evaluations. A secondary objective will evaluate if differences in faculty characteristics affect perceived confidence gains after training.

Methodology 
This AMA ChangeMedEd grant project utilized a faculty development session in April 2025 led by curricular leaders in the Office of Medical Student Education. There were 78 participants which included clerkship directors and clinical preceptors with previous experience in writing student evaluations.

Major components of the workshop included review of data regarding biased language in narrative evaluations, introduction of a structured framework, and interactive application exercises. A retrospective pre-post survey was offered after the session with confidence categories rated by a 5-point Likert scale. The survey remained active for ~ 1 week to allow asynchronous completion. An in-house evaluation consultancy utilized descriptive statistics to analyze average change in self-reported confidence before and after the training by role, rank, and years of experience. 


Results 
Of 78 participants, 41 began the survey (53% initiation rate), and 13 completed it (17% completion rate). The Dean role had the highest average years of experience in their position (10 years) and in medical education (30+ years). The Clinical course director role had the lowest average years of experience for position (4 years) and medical education (4 years). Highest confidence gains were reported in Assistant professors (+0.50), Department medical directors (+0.47), and Phase leaders (+0.46), while Deans and Associate professors had the smallest confidence change (+0.08).

Conclusion/Significance 
Our results suggest that some faculty with less experience may be less anchored in routine and more open to change their evaluation writing style. Faculty with more years in medical education and position had smaller shifts, which may represent familiarity or less perceived need to change. Future directions should explore options for tailoring workshops based on participant years of experience. Identifying these strategies may help streamline workflow for busy clinicians while also maximizing competency-based narrative assessments that showcase students’ strengths.



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