United States

Background
Preoperative marking is an essential safety practice to prevent ‘never’ events, including wrong site surgery. Moreover, the Joint Commission regulations of Universal Protocol require that patients be marked to indicate the operative site. Marking typically occurs with a pen or marker that may be disposable or reusable. Previous studies have demonstrated that methicillin-resistant staphylococcus aureus (MRSA) can survive in the dark, moist, capped environment of the marking pen and thus, could plausibly be a nidus for transmission from patient to patient. The Joint Commission has established no increased risk of postoperative infection with these markings. With this study, we aimed to determine the colonization of surgical marking pens in the plastic surgery population.

Methods
Two marking pens from five different attending plastic surgeons at a single institution were cultured in standard fashion for aerobic and anaerobic growth. All pens were used repeatedly in office settings for performing patient markings. Those same ten marking pens were then used to mark incision sites on mock patients. Standard povidone-iodine prepping was then performed in a paint only fashion over the skin markings and cultures were again taken. A control group consisted of cultures from five sterile pens from the operating room. Each sterile pen was opened, uncapped, and then swabbed. All twenty-five cultures were analyzed in the hospital laboratory in a blinded fashion.

Results
The five control pens revealed no bacterial growth. Of the ten direct pen cultures, two samples grew coagulase-negative staphylococci and one culture contained pseudomonas aeruginosa. The ten-patient marked and prepped specimens showed 8 negative cultures and two with coagulase-negative staphylococci. Although pseudomonas was detected on standard pen culture, no pseudomonal growth was present in any of the samples after patient marking and prepping with povidone-iodine.

Conclusion
Our findings reaffirm that marking pens may be vehicles for bacterial transmission and expands upon previous studies by describing the presence of bacterial colonization on marking pens even after surgical site preparation with povidone-iodine.

2022 AMA Research Challenge

Surgical Marking Pen Contamination: Writing a postoperative infection into your preoperative plan

Welcome to the largest national, multi-specialty research event **featuring research from 750 medical students, residents and fellows, and international medical graduates.**


#### Event Details
The 2022 American Medical Association Research Challenge includes a poster symposium hall and a semifinals hall with the top scored research. Log in at any time throughout the event to:
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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 sponsored by Laurel Road.
 

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 **Speakers**
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Ricardo Correa, MD, EdD
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Stuart M. Greenstein, MD
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Stephanie Strohbeen, MD
 
 **Oct. 22, 11 a.m. — Noon Central**
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Jessica Li, MD/PhD Candidate
![](https://assets.underline.io/uploads/markdown_image/1/image/9950ef2e0237f54cb3d8280334d42491.jpg)
Charles Lopresto, DO

### 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 the judging or scoring process to select the winner. The winner will be announced on Dec. 7 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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**There is no registration fee for this event! **

Register to explore research in a variety of topics. AMA members get exclusive access to score posters in the semifinals.

**Please use the link below to register for free if you have not already done so:**

https://www.ama-assn.org/about/events/ama-research-challenge

Registration Is Required

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


poster

Background:
Acellular dermal matrix (ADM) has become commonplace in reconstructive surgery despite incomplete FDA safety and efficacy clearance and high cost. Further, it has been the focus of approximately 500 plastic surgery publications since its wide adaptation. An aim of this investigation was to describe external factors associated with the rise of ADM usage over the past two decades. Attention was paid to report individual ADM-related academic output and correlation with industry funding or public interest in the costs of plastic surgery. 

Methods:
All PubMed indexed studies focusing on ADM, in eleven plastic surgery journals, were included (n=534). Data on industry funding to the 17 authors with five or more first and last author publications were extracted from the Open Payments Database. To measure public interest, Google Trends in “plastic surgery cost” and “breast surgery cost”-related searches were queried. Relationships between publication quantity, author industry funding, and public interest were analyzed by Pearson’s Correlation and linear regression.

Results:
ADM-focused studies were published at an approximate rate of 4/year from 2000-09 with a precipitous peak to 71 publications in 2012 and subsequent normalization to approximately 36/year. The 17 most-published authors produced eight qualifying publications on average [5-17]. These individuals grossed a total of $19million industry dollars overall with $17M (89%) in non-consulting compensation from ADM-producing companies (NC-ADM). 

Median/quartile individual total compensation and NC-ADM compensation were $194K/$320K/$1.25M and $17K/$210K/$1.1M respectively. These variables showed strong correlation with individual publication rate [r=0.662 & r=0.647, (p<0.01*)] with a linear regression coefficient of $110K per NC-ADM publication (p< 0.01*). Authors disclosed funding in a mean of 65+/-26% of their work with strong correlation between disclosure and NC-ADM (r=0.576, p=0.02*). Google trends in searches for “breast surgery cost” have risen precipitously in strong correlation with ADM-related publications (r=0.671, p<0.01*). 

Conclusions:
This study demonstrates significant correlations between ADM-related publication, industry funding, funding disclosure, and public interest. Education in the potential for such relationships and the importance of objectivity in operative protocol design is necessary. Continued analysis for potential biases in evidence and transparency in publication are critical when adopting new techniques and technology.

The Rise of Acellular Dermal Matrix: Cost Consciousness, Industry Payments, and Publication Productivity

Background: Renal colic represents a leading cause of emergency department (ED) presentation nationally, yet most require neither hospital admission nor surgical intervention. While not historically considered an ambulatory care-sensitive condition—a condition for which effective outpatient management may prevent admission—we hypothesize that urinary stone disease may share many features, such as high prevalence in socioeconomically disadvantaged populations. No research currently exists on the frequency and characteristics of preventable ED visits for renal colic. We investigated factors associated with potentially avoidable ED visits and their economic burden.

Methods: Patients presenting to the ED for index renal colic events were selected using Florida and New York all-payer data from the 2016 Healthcare Cost and Utilization Project State Databases. Avoidable visits were defined as those that did not result in intervention, admission, or referral to an acute care facility. Utilizing multivariable logistic and linear regression, researchers discerned patient and facility factors predictive of avoidable ED presentations and associated costs.



Results: Of 167,102 renal colic-related ED encounters, 68.2% met pre-determined criteria as potentially avoidable, with cumulative costs totaling $229,269,273.77 over one year. Associated factors included Hispanic ethnicity (Hispanic vs. white: OR 1.12, 95%CI 1.02-1.24: p=0.02) and rural care settings (rural vs. large metropolitan OR, 1.41 95%CI 1.26-1.59: p=0.001). Conversely, increased comorbidities (Elixhauser score ≥3 vs. 0: OR 0.02, 95%CI 0.02-0.02: p<0.001), lower education (≥13% less than high school level education vs. <9.7%: OR 0.73, 95%CI 0.63-0.86: p<0.001), female gender (female vs. male: OR 0.76, 95%CI 0.73-0.79: p<0.001), and Medicare/Medicaid beneficiary status (Medicare vs. private: OR 0.64, 95%CI 0.60-0.67: p<0.001)/(Medicaid vs. private: OR 0.70, 95%CI 0.66-0.75: p<0.001) were protective against avoidable visits. Experiencing an avoidable visit was associated with more renal colic-related ED encounters (OR 4.01, 95%CI 3.69-4.36; p<0.001).

Conclusion: Several non-clinical factors are associated with potentially avoidable ED encounters for renal colic. Given the frequency of presentations that we posit may have been safely managed in outpatient or urgent care settings, our findings support investment into outpatient diagnostic and procedural alternatives to inpatient care, instead diverting patients to lower-acuity care settings. If appropriately targeted, standardization of care may reduce spending without compromising care.

Predictors of Potentially Avoidable Emergency Department Presentations for Renal Colic and Their Associated Costs

Background:
Clinical trials often struggle to enroll participants. Unnecessarily varied eligibility criteria create barriers to clinicians offering trials, particularly if the variation has limited clinical significance (e.g., eGFR 45 vs. 60; ECOG 1 vs. 2). However, the degree of variation in trial eligibility criteria remains poorly characterized. For these reasons, we analyzed the variability in eligibility criteria of genitourinary cancer trials at our institution.

Methods:
We extracted eligibility criteria from protocol documents for active genitourinary cancer trials at our institution. We grouped and compared eligibility criteria within prostate cancer and bladder cancer trials. 

Results:
We identified 35 active genitourinary cancer trials at our institution. Eligibility criteria were highly varied. For example, in prostate cancer trials (n=25), there were 6 different kidney function criteria (4 eGFR and 2 creatinine cutoffs). For all trials, there were 7 different eGFR cutoffs (25, 30, 40, 45, 50, 51, 60) with marginal practical implications. Other criteria were similarly varied. 

Conclusion: 
Trial eligibility criteria have unnecessary variation. These variations are of dubious clinical significance but increase the complexity of trials and may decrease trial acceptability, adoption, and patient enrollment. Simplifying trials, perhaps by creating standards for trial eligibility criteria, may address these barriers. Such standards could make trials more acceptable, less expensive, and more feasible through diminished administrative burden. 


Unnecessary Variation in Clinical Trial Eligibility Criteria: a Call for Standardization

Background: Electronic health records (EHR) were implemented to improve patient care, reduce healthcare disparities, engage patients and families, improve care coordination, and maintain privacy and security. Unfortunately, the mandated use of EHR has also resulted in significantly increased clerical and administrative burden, with physicians spending an estimated three-fourths of their daily time interacting with the EHR, which negatively affects within-clinic processes and contributes to burnout. In-room scribes are associated with improvement in all aspects of physician satisfaction and increased productivity, though less is known about the use of other technologies such as GG, Natural Language Processing (NLP) and Machine-Based Learning (MBL) systems. Given the need to decrease administrative burden on clinicians, particularly in the utilization of the EHR, there is a need to explore the intersection between varying degrees of technology in the clinical encounter and their ability to meet the aforementioned goals of the EHR.

Aims: The primary aim is to determine predictors of overall perception of care dependent on varying mechanisms used for documentation and medical decision-making in a routine clinical encounter. Secondary aims include comparing the perception of individual vignettes based on demographics of the participants and investigating any differences in perception questions by demographics of the participants.

Methods: Video vignettes were shown to 498 OhioHealth Physician Group patients and to ResearchMatch volunteers during a 15-month period following IRB approval. Data included a baseline survey to gather demographic and background characteristics and then a perceptual survey where patients rated the physician in the video on 5 facets using a 1 to 5 Likert scale. The analysis included summarizing data of all continuous and categorical variables as well as overall perceptions analyzed using multivariate linear regression with perception score as the outcome variable.

Results: Univariate modeling identified sex, education, and type of technology as three factors that were statistically significantly related to the overall perception score. Males had higher scores than females (p=0.03) and those with lower education had higher scores (p<0.001). In addition, the physician documenting outside of the room encounter had statistically significantly higher overall perception scores (mean=22.2, p<0.001) and the physician documenting in the room encounter had statistically significantly lower overall perception scores (mean=15.3, p<0.001) when compared to the other vignettes. Multivariable modeling identified all three of the univariably significant factors as independent factors related to overall perception score. Adjusted least squares means (LSM) were calculated and males had higher scores than females (LSM=20.7 vs. 19.9, p=0.03). Those with lower education had higher scores (p<0.001). Specifically, high school education had higher scores than associate/bachelor education (LSM=21.6 vs. 19.9, p=0.0002) and high school education had higher scores than master/higher education (LSM=21.6 vs. 19.5, p<0.0001). Differences in technology were found with the physician documenting outside of the room encounter having significantly higher overall perception scores (LSM =22.6) and physician documenting in the room encounter having significantly lower overall perception scores (LSM =15.7) compared to the other vignettes. No differences between age groups were found on the individual perception scores. Males had higher scores than females on ‘The doctor clearly explained the diagnosis and treatment to the patient’ and ‘The doctor was sincere and trustworthy’. High school education had higher scores than associate/bachelor and master/higher on all five individual perception scores.

Conclusion: The study found sex, education, and type of technology were significant indicators for overall perception of varying technologies used for documentation and medical decision-making in a routine clinical encounter. Importantly, the vignette depicting the least interaction with the EHR received the most positive overall perception score, while the vignette depicting the physician utilizing the EHR during the interaction received the least positive overall perception score. This suggests patients most value having the full attention of the physician and feel less strongly about differentiating the logistics of data transcription and medical decision-making, provided they feel engaged during the interaction. Therefore, the authors suggest maximizing face-to-face time in the integration of technology into the clinical encounter, allowing for increased perceptions of personal attention in the patient-physician interaction.

Assessment of Patient Perceptions of Technology and theUse of Machine-Based Learning in a Clinical Encounter

Background: 
• Sleep disruption occurs in two-thirds of patients in the hospital due to the unfamiliar and stressful environment characterized by illness and discomfort, a preponderance of noise and light, and around-the-clock interventions. 
• Effects of sleep deprivation include decreased immune function, higher heart rate and blood pressure, increased insulin resistance, decreased cognitive function and alertness, increased rate of falls and delirium, increased length of hospital stay, and impaired social interactions.
• Clustering care allows patients to receive uninterrupted rest and has demonstrated positive effects on sleep quality and quantity. 
• Rest improves outcomes, length of stay, satisfaction scores, and fall rates and reduces the need for medications 

Methods
This quality improvement study is being conducted on a general Medicine floor in Queens Hospital Center, New York. To minimize patient interruption during the night hours, designated hours of uninterrupted sleep (11 pm-5 am) for all admitted patients were implemented. 
Interventions: 
• Avoiding drawing labs, checking finger stick blood sugar, and taking vitals or any patient care between these hours in non-emergency situations.
• Avoiding giving medication during this time unless it was an emergency.
• Minimizing the amount of noise and light and silencing unnecessary sounds to ensure a proper environment for patients to get sound sleep. 
A PICOT (population, intervention, comparison, outcome, and time frame) questionnaire has been developed to administer surveys to discharged patients upon leaving the hospital about their sleep quality, injury or falls, overall concerns, and satisfaction


Results
Intervention or Uninterrupted sleep cycle (%)/ Control or interrupted sleep cycle (%)
1.Woken up an appropriate amount of time during the night- 82.1/70
2.Believed that overnight awakenings did not significantly affect them the next morning- 77.8/60
3.Believe health concerns have improved significantly-46.4/20
4.Likely to visit the same hospital for future health concerns -57.1/55


Conclusion
• The areas of the hospital where the sleep cycle of the patients was not interrupted showed a significant improvement and rectification of their health concerns.
• This should encourage hospital administration to implement improved plans for uninterrupted sleep cycles while promoting better healthcare.






Better Sleep,Better Healing:Sleep Improvement Project at Hospital Setting

Background: According to the World Health Organization (WHO), 1 in 6 people will be ages 60 or older by 2030. With existing age-related preconceptions such as older adults being “frail” or a “burden”, it is crucial for physicians to understand how to care for older patients, especially when they are marginalized by both age and other factors like gender, immigration status, and income. Resident physicians have limited and varied geriatric and social justice training. The objective of this study is to develop a social justice curriculum with a module focusing on senior care.

Methods: Literature reviews were conducted on PubMed articles to summarize important factors when providing care to older adults. Search terms included: “ageism” AND “elder care” (n=32 results), “best practices geriatrics” (n=2,614 results), “screening for elder abuse” (n=932 results), and “family support” AND “elders” (n=2,812 results). Of these, 20 articles were selected to compile major themes into a document that is provided to residents during the curriculum.

Results: Key senior care and social justice practices are: (1) collaborate and create goals important to the patient, (2) use age-inclusive language, (3) communicate with others involved in patient’s care to establish an interprofessional team, (4) assess fall risk when necessary and provide recommendations to reduce falls given a patient’s environmental context, (5) eliminate unnecessary medications and provide financial resources for medications, (6) screen for elder abuse.

Conclusion: There are key evidence-based knowledge, attitudes, and skills that focus on unique healthcare needs of older adults who may also be marginalized by society with intersecting identities (e.g., refugees, unhoused individuals). Training resident physicians with this focus may allow them to better advocate for their patients’ goals. Next steps are to evaluate the effectiveness of this curriculum.

Development of a Social Justice Curriculum: Best Practices for Senior Care and Age-Inclusive Medicine

Title: Validating the Utility of Standard Operating Procedures In a Student-Run Free Clinic
Background: Student-Run Free Clinics are common at medical schools across the country. These clinics face unique challenges with continuity due to annual changes in leadership. In this pilot study, we aimed to stabilize the leader transition process by creating standard operating procedures (SOPs) for each position in the MedZou Specialty Clinic.
Methods: MedZou Specialty Clinic SOPs for 2021 and 2022 were assessed via survey. Participants rated quality of SOPs and their self-assessed preparedness. All ratings were measured on a scale from 1 to 5, with 1 representing the lowest quality or least prepared and 5 representing the highest quality or most prepared. An optional free-response was also included.
Results: In 2021, only 7 of 11 student leaders received a SOP during training. Upon study completion in 2022, all 11 incoming student leaders received a SOP. There was an observed increase in average quality (P<.001) and self-assessed preparedness (P= .006) between cohorts.
Conclusion: Providing SOPs during the MedZou training period correlated with increased satisfaction and confidence in incoming student leaders. Implementation of SOPs for all MedZou clinics may be helpful for creating smooth transitions for future leaders.

Validating the Utility of Standard Operating Procedures in a Student-Run Free Clinic

Background: The rising prevalence of physician burnout in recent years has drawn significant attention. The COVID-19 pandemic has resulted in additional strain on healthcare staff working tirelessly for extended hours, amplifying physical exhaustion and emotional stress levels. Physicians in training (residents) have been considered to be at increased risk of burnout, even before the pandemic. With limitations in social interactions and travel restrictions, the possibility of interventions to prevent burnout has significantly reduced. We conducted a study to assess the impact of the COVID19 pandemic on self-reported burnout among internal medicine residents at our hospital.

Methods: The Oldenburg Burnout Inventory was used as the screening tool. Residents filled out a mid-year questionnaire in December 2019 [pre-COVID period] and in December 2021 [COVID period]. The survey was voluntary, anonymous, and confidential. The inventory included a total of 16 questions divided into disengagement and exhaustion categories. Residents scored the questions between 1 through 4 [strongly agree to strongly disagree]. Overall, burnout scores were characterized as high [score >2.17], medium [1.0-2.17], and low [<1] for the disengagement category. In the exhaustion category, burnout scores were characterized as high [>2.57], medium [1.67-2.57], and low [<1.67]. The degree of burnout among residents before and during the COVID pandemic was compared based on cohort/ level of training. pre-COVID pandemic and during the pandemic. A higher score indicated suggested more burnout among residents. The one-way ANOVA test and unpaired T-test were used for statistical analyses, as appropriate.

Results: 75 responses were obtained during the pre-COVID period, and 43 responses were obtained during the COVID period. Comparing the first-year trainees [PGY1], pre-COVID and during COVID, there reported more burnout [p<0.0001] during the COVID pandemic. During COVID, first-year trainees [PGY1] reported significantly more burnout as compared to PGY2 [p=0.025] and PGY3 [p=0.0018] trainees with higher burnout scores. The level of burnout was not statistically significant between PGY2 and PGY3 trainees [p=0.95]. In the disengagement category, The residents scored highest in questions concerning disengagement over time, the question being if this was the only type of work they can see themselves doing. In the exhaustion category, residents reported that they felt tired before arriving at work and needed a longer time to relax to feel better after work. They felt worn out easily quickly, not having enough energy for leisure activities.

Conclusion: The data suggest that there is comparably more burnout among PGY1 with learning a new healthcare system and electronic medical records(EMR)s, adjusting to new work schedules and living conditions as possible contributing factors. In comparison, concern for future career/fellowship applications is a potential source of concern for PGY2. Our observation of increased burnout among the current PGY1 who started their training during the pandemic raises questions about how well they were prepared to face a healthcare crisis. Meanwhile, during their second and third years of training, residents have gathered more skills and knowledge which enhance their resilience and ability to cope with unprecedented demands on the healthcare system.

A Comparison of Burnout Among Internal Medicine Residents in Different Post-Graduate Years of Training in a Community Hospital During the COVID-19 Pandemic

Background: Supplementary medical school learning resources, including textbooks, United States Medical Licensing Examinations (USMLE) preparatory materials, and internet searches have all been shown to lack equitable representation of brown and black skin images. This creates a knowledge gap for learners and decreases providers’ confidence managing skin disease in all populations. Subsequently, patients with non-white skin experience delayed or missed diagnoses, which contributes to known skin health disparities. Here, we aimed to create a standardized course auditing system to assess the use of brown and black skin images in the preclinical medical education.

Methods: We performed a cross-sectional audit of the 2020-2021 preclinical curriculum at the University of Pittsburgh School of Medicine (UPSOM). All human images in the learning material for 34 first- and second-year medical school courses were analyzed. Skin color was categorized as light/white, medium/brown, and dark/black using the Massey-Martin NIS Skin Color Scale.

Results: In total, 1,660 unique images were analyzed; 71.3%, (n=1,183) were light/white, 16.1% (n=267) were medium/brown and 12.7% (n=210) were dark/black. Dermatologic images of skin, hair, nail, or mucosal disease made up 62.1% (n=1,031) of the images and 68.1% (n=702) of the dermatologic images were light/white. Images of infectious diseases were more frequently presented in darker skin colors (χ2(2) = 15.46, p<.001). 

Conclusion: White skin was the standard used for visual learning images. These results further substantiate the lack of representation of brown and black skin in medical education. Using our efforts as a model, we propose guidelines to achieve visual learning equity. First, institutions should create a taskforce to implement a similar course auditing system. Medical school educators should be informed to present skin conditions on a spectrum of skin colors (white, brown, and black skin) to demonstrate differences in disease manifestations based on constitutive skin type. Resources with high quality images of brown and black skin should be made accessible for editing learning material. Course content should be audited regularly with feedback and support given to instructors. It is paramount that we analyze and revise our medical school curricula to ensure the next generation of physicians are educated to care for all patients.

Achieving Visual Learning Equity: A Course Auditing System of Skin Color of Images in Preclinical Medical Education

Addressing Instances of Racism, Discrimination, and Microaggression in Medical Education in Puerto Rico: A Symposium in Diversity, Equity and Inclusion

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Surgical Marking Pen Contamination: Writing a postoperative infection into your preoperative plan

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