United States

Background
The use of race as a biological construct without proper social, political, and historical context is dangerous and can lead to the perpetuation of racism and racial and ethnic health disparities.1–4 The goal of this project was to assess the ways in which race and ethnicity are presented in the Foundations of Medicine and Health pre-clerkship curriculum at Case Western Reserve University School of Medicine and appreciate ways in which the curriculum could improve to be more structurally competent.

Methods
This project began by creating ten learning objectives to guide instructors and students on the skills and knowledge necessary to promote race and ethnic diversity in medicine. We systematically reviewed 398 lectures with 20,630 slides across six basic science integrated blocks from 2020-2022 looking for the following terms: race, ethnicity, black, white, asian, hispanic, native American, racial, or photos of people of color. Each lecture PowerPoint was reviewed for the relevant terms and images; and the following information was recorded for each reference: faculty author, block, lecture title, number of slides in that lecture that mentioned key
terms, topic covered in the lecture that included race-ethnicity, application of the term (e.g risk, diagnostic), and areas for improvement.

Results
The results of this project were the creation of 10 learning objectives that are consistent withmCultural Competence Education for Medical Students guidelines AAMC standards. Curricular examination identified 245 slides across ninety lectures in the 2020-2022 preclinical curriculum that mention race, ethnicity, black, white, Asian, Hispanic, Native American, racial, or contain photos of racially and ethnically diverse people. Of the 245 slides reviewed, 220 slides (89%)
mentioned key terms as biological constructs without proper mention of structural factors.
Conclusion
The results of this project are in alignment with previous literature on the subject.17
Added context should be included throughout all the preclinical curriculum to ensure that students are prepared to effectively care for individuals from a variety of races and ethnic backgrounds. Moreover, medical education still lacks a concise and direct way to discuss race and ethnicity. The learning objectives created in this project offer a framework on how to make discussion on race and ethnicity in medicine relevant, accurate, and solution oriented.

2022 AMA Research Challenge

An institutional evaluation of race and ethnic diversity in pre-clerkship lectures

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Charles Lopresto, DO

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Background: Physicians regardless of specialty will encounter patients who have experienced addiction, making addiction medicine training vital. Unfortunately, medical schools devote little time to addiction-related training, with many students graduating without adequate knowledge or skills to treat patients with substance use disorders (SUD).

Methods: Michigan State University (MSU) created a pilot 4-week addiction medicine elective for PGY-1 students with the goal of increasing student’s knowledge, awareness, and skills in assessing patients with SUD. The Addiction Medicine Student Interest Group (AMSIG) was created to implement additional foundational principles. The 4-week elective was developed and made available to students online, including asynchronous modules, small and large group meetings, clinical cases, and expert and patient interviews. Utilizing these methods allowed for a broader reach and appealed to multiple learning styles. AMSIG held several events beginning with a de-stigmatization campaign where people-first language was emphasized. Other events included a patient panel, and naloxone and buprenorphine educational sessions.

Results: 36 PGY-1 students at MSU-CHM (MSU College of Human Medicine) completed a baseline attitudes survey in May 2021. An overwhelming majority of students “agreed” or “strongly agreed” that physicians who diagnose SUD early improve the chance of treatment success (89%), family involvement is a very important part of SUD treatment (97%), SUD is treatable (92%), alcohol use disorder is treatable (97%). The majority “disagreed” or “strongly disagreed” that once a patient is abstinent and off all medication for their SUD, no further contact with a physician is necessary (100%), a patient with SUD who has relapsed several times probably cannot be treated (100%), a patient with a SUD cannot be helped until they hit “rock bottom” (94%). The de-stigmatization campaign had 21 participants, the patient panel had 30 attendees, the naloxone training was overwhelmingly popular with 66 participants, and the buprenorphine session had 26 participants.

Conclusion: Early supplementation of the medical school curriculum with addiction medicine training can boost students’ confidence in their ability to assess patients with SUD. Moving forward, the goal is to share what MSU-CHM has learned from the elective and AMSIG. Our hope is that other medical schools will incorporate these principles into their curriculums.

Beyond the Curriculum: Equipping Medical Students to Respond to the Opioid Epidemic

Background
Violence by patients and families against healthcare providers has long been a documented problem among healthcare professionals, and medical students are no exception. There is existing evidence of the effectiveness of verbal de-escalation to prevent violence and restraint. However, most medical schools do not offer de-escalation training, and most health system employers don’t have training or policies about managing aggressive behaviors. 
Methods
A group of researchers worked with medical college faculty and resources to develop a one-hour verbal de-escalation training for students based on the 10 de-escalation principles outlined in Project BETA and delivered the class to fourth-year students. During and after class, surveys were distributed to students for reflection and to assess the efficacy of the educational intervention. There were 158 recorded responses to the survey of 192 students in the graduating class.
Results
Overall, 82% of respondents thought that the course was at least somewhat of a good use of their time, and 97% of respondents felt that they would be successful in their attempts to de-escalate a patient after participating in the class. Students reported learning about de-escalation tools that will be useful, and that violence and the use of restraints are preventable with verbal de-escalation. Although most students reported increased confidence in de-escalation after participating in the course, it is unclear whether the topics in this course are readily applied to real-life situations; a limitation of the data collected.
Conclusion
Although a one-hour course is a strong step in teaching students about de-escalation, de-escalation is a learned skill that takes practice. Regular intervals of de-escalation learning throughout medical training would be ideal for the continued retention of information and practice of its use.


De-Escalation Training in Medical Students

Spaced-repetition and active retrieval-based practices consistently demonstrate improvement in cognition and retention of a large volume of information. Anki is an application that capitalizes upon these techniques and is increasingly utilized by medical students for exam preparation. While both spaced-repetition and active retrieval have been shown to improve long-term memory, there is little research on using Anki supplementary to medical curricula. This study examines how Anki utilization affects performance on standardized exams alongside analyzing individual Anki statistics to track markers of quality usage. Secondary goals include a qualitative assessment of the Anki, including its effect on student test confidence and preparedness.

In July 2021, medical students received training on using Anki alongside longitudinal support throughout the year. Following completion of Boonshoft School of Medicine academic curricula, data was obtained from the exams: Origins, Host and Defense (H&D), Staying Alive (SA), and the Complete Basic Science Exam (CBSE). Variables included: (1) student generated information from individual Anki-user statistics, submitted via Qualtrics; (2) nationally standardized exams stored in the Department of Medical Education; and (3) Qualtrics surveys on perceived ease-of-use at course end points.

Of the 130 students from the Class of 2025, 78 students reported using Anki for at least one of the exams, and 52 students were not in any of the four datasets. MCAT scores were used as a controlling measure when analyzing test scores to diminish confounders of natural intelligence and test-taking ability. Anki users scored significantly higher (95% CI) across all for exams: Origins (6.37%; p<0.001); H&D (6.15%; p=0.002); SA (7.01%; p<0.002); and CBSE (12.9%; p=0.003). Additionally, students who reported higher confidence or Anki dependency performed significantly better on the CBSE (ANOVA p=0.008, R2 = 74.8%).

Students more dependent on Anki performed significantly better on standardized examinations. Of interest, Anki efficacy was more pronounced in exams requiring greater bouts of knowledge, emphasizing the importance of long-term retention practices for board exams. In summary, greater integration, training, and longitudinal support of Anki may improve foundational biomedical knowledge and standardized exam scores.

From Short-Term Memory to Long-Term Knowledge: A Modified Learning Approach to First-Year Medical Education

Abstract Title: From Stage to Clinic: The Implementation of the Theater of Oppressed in Medical Education

Background
Structural and social determinants of health (SSDOH) studies are an essential part of medical education. Previous work has demonstrated increased awareness and reflexivity of SSDOH topics among students. This skill, however, does not always translate into a tangible behavioral change. The complexity of SSDOH does not lend itself well to didactic teaching styles or even traditional active learning modalities like TBL and CBL. These approaches often lead to SSDOH being presented as a laundry list of problems rather than a multifaceted problem originating from societal systems of power. Theater of the Oppressed is a pedagogical method derived from Brazilian theatrical studies. In Theater of the Oppressed, the actors and audience work together to practice action-based change that stimulates critical observation and representation of reality, as well as allow for the envisioning and production of conscientious and concrete actions. Theater of the Oppressed has great utility in medical education and opportunity to incite behavioral change. 

Methods
To create a pilot test of the Theater of the Oppressed in medical education, a focus group was held with current medical students to assess what SSDOH topics they were interested in, or felt they were lacking in their medical education. These topics were used to write a five-person scene featuring an oppressor, a victim, and several bystanders. Volunteer actors rehearsed the scene and practiced improvised situations prior to the pilot session. 

Results
Second through fourth year medical students watched a live scene depicting the relationship between an oppressor and victim. Using previous knowledge of SSDOH and existing interpersonal communication skills, after the scene students were able to switch with an actor to try and alleviate the oppression. This engaged students in SSDOH discussion and allowed for the practice of tangible intervention. 

Conclusion
Theater of the Oppressed has a large utility in improving SSDOH medical education. Future installments will use a Likert scale and free response questions to survey participants before and after a session. The survey will evaluate for general understanding of SSDOH, perceived ability to alleviate health inequities, and overall benefit of Theater of the Oppressed in medical education.


From Stage to Clinic: The Implementation of Forum Theatre In Medical Education

Background:
Hearing loss affects 1.6 billion people, making it the third most common disability worldwide. Patients who can hear are approximately 2 times more likely to secure primary care appointments than those who are deaf and communicate via American Sign Language (ASL). Compounding factors such as inadequate sign language interpreter services and the COVID-19 pandemic have exacerbated the existing healthcare service disparities received by the deaf population. Additional studies show that despite having similar health insurance coverage percentages (Deaf=96% covered; Hearing=94% covered), deaf patients rated their doctors as having lower patient-centered communication skills than those who hear (Deaf patient centered communication satisfaction mean=60.99 [SD=25.89]; Hearing patient centered communication satisfaction mean=82.25 [SD=21.14]; t test=16.97, P value<.001). Despite this, there is still a lack of formal training for frontline health professionals working with this disadvantaged population. 

Methods
The dire need for ASL interpreter services can be alleviated by introducing an ASL elective to medical school programs and other health professional school curriculums. Language electives, including medical Spanish, are currently offered by 78% of 125 U.S. medical schools in response to the growing Spanish-speaking population, yet very few medical programs offer an elective to teach ASL. Our proposed ASL elective would be modeled similarly to current language electives to confront this seemingly timeless disparity.

Results
Through collaboration with local ASL community centers, including churches and colleges, health professional programs across the nation can develop a 4-week ASL elective through clubs or service-learning projects. Offering such an elective would ultimately help produce better prepared future healthcare professionals, especially those interested in ENT, audiology, and primary care specialties.

Conclusion
The Americans with Disabilities Act (ADA) mandates equal access and effective communication to all patients, especially those with disabilities; however, ASL interpreter services are not readily available or reimbursed by all healthcare systems and insurances. Furthermore, the COVID-19 pandemic enforced mask mandates which prevents deaf patients from reading lips, thus hindering one of few alternative communication methods apart from ASL. The call for reformation in the medical healthcare system to alleviate the perpetual struggles of the deaf population is one that needs to be heard now.

Health Care Disparities Among the Deaf Call for Health Professional Education Reformation

Abstract Title:
Image Quality Assessment in Point of Care Ultrasound Education
Background
Our aim was to provide a high-quality POCUS education program for hospitalists at the Jesse Brown VA hospital. That entailed providing a valid and consistent way of tracking the progress of our learners throughout the program, for which image quality assessment was one of the main metrics. Literature review demonstrated a gap in evidence-based methods for doing so, which is why we believe our findings are invaluable for the advancement of POCUS education.
Methods
A group of 25 ultrasound images was shared with our 3 educators for quality measurement on a numerical scale. First, each educator independently scored the images based on clinical gestalt. A second round of image scoring was done where the educators were provided a rubric to independently score images based on orientation, gain, plane, depth, and visible structures. A debriefing session was then done to clarify how each of the educators perceived and utilized the rubric after which a third and final round of image scoring was done. The educators were blinded to their colleagues’ grading submissions until the end of the 3 rounds.
Results
The intraclass correlation coefficient (ICC) was 0.589 for the first round of scoring. After adding the rubric, the ICC rose to 0.752 (28% increase). The ICC further increased to 0.862 after the debriefing session was done on using the rubric. The calculated Conbrach’s alpha for internal consistency was 0.811.

Conclusion
There is a significant improvement in the ICC after implementing the rubric, and again after the debriefing session was conducted. This implies a higher consistency in the feedback learners receive on their images from the different educators when using an agreed-upon rubric to track their progress. 
The rubric was also successful in grounding the educators to focus on the innate image quality attributes first, and then to provide feedback on the clinical utility of the entire study of images a learner has submitted for a given patient. We were thus able to independently score technical skills for image acquisition while fostering the learner’s clinical skills of interpreting such images to guide their use of ultrasonography in clinical practice.

Image Quality Assessment in Point of Care Ultrasound Education

Abstract Title:
Impact of Medical School Longitudinal Research Program in Post-Graduate Research Productivity

Background
In 2004, the University of Pittsburgh School of Medicine (UPSOM) implemented a novel, mandatory research curriculum for medical students titled the Longitudinal Research Project (LRP). Under faculty mentorship, medical students construct an individualized scholarly research project that must be completed prior to graduation. This study evaluates the long-term implications of the LRP by analyzing post-graduate research productivity following the implementation of this unique research curriculum.

Methods
This retrospective study analyzed publication data from 2007-2020 on UPSOM graduates before and after LRP implementation in 2004. Each graduate’s respective publication(s) were identified via PubMed’s Advanced Search Builder with a time frame that began from one-year to seven-years post-graduation. Confounders were identified using bivariate analyses and incorporated into final multivariate regression models. The cross-sectional time series cohort was analyzed using multivariate linear mixed effects modeling with significance set to 0.05 via STATA 16 statistical software.

Results
1,022 medical school graduates met inclusion criteria. Of which, 278 graduated prior to 2008 (pre-LRP), while 744 graduated in 2008 or later (post-LRP). The average rate of publications annually was 0.47 + 1.43 pre-LRP & 0.57 + 1.40 post-LRP. According to multivariate linear-mixed effects results, post-LRP medical school graduates exhibited a greater average annual publication rate than pre-LRP medical student graduates (ß = 0.10, 95%CI: 0.03 – 0.17, p = 0.008). The average probability of at least one publication in a given year was 22% (95%CI: 0.21 – 0.23) pre-LRP & 27% (95%CI:0.25 – 0.28) post-LRP. The average probability of at least one first author publication in a given year was 12.2% (95% CI: 0.12 – 0.13) pre-LRP & 15% (95% CI:0.14 – 0.16) post-LRP.

Conclusion
Medical school graduates who partook in a mandatory, longitudinal research program in a medical school curriculum exhibited a greater average annual publication rate than pre-LRP medical graduates early on in their post-graduate careers. This study suggests that implementing a mandatory LRP within a medical school’s curriculum may increase meaningful research productivity and progression of clinical science for young physicians beyond the curriculum.



Impact of Medical School Longitudinal Research Program in Post-Graduate Research Productivity

Medical law is a subset of the legal system that dictates appropriate medical practice, regulations, and the rights and responsibilities of healthcare professionals and their patients. As the relationship between medicine and law becomes increasingly complex, many medical students report negative perceptions of the legal field and feel unprepared to handle medical-legal issues upon entering their clinical rotations and residencies. The aim of this literature review was to provide an overview of medical student understanding of medical law as well as the current status of medical-legal education in the United States. 

A PubMed search revealed 3,483 papers that were sorted for relevance and the citations of relevant papers were also reviewed. A total of 38 studies were included and evaluation yielded three main themes that were explored in depth. The first theme was that medical students and residents report feeling unprepared to handle legal aspects of healthcare. Surveys regarding medical student perceptions of the legal field unveiled the second theme which describes students as having generally negative feelings and attitudes toward law, although students acknowledged the importance of medical law in healthcare. The last theme was described by studies determining that introducing medical-legal courses to current medical school curricula would benefit students and have a positive impact on their perceptions of the legal field. 

More must be done to evaluate and reform current medical curricula to produce legally competent and confident physicians. The Liaison Committee on Medical Education in the United States should take the lead and add medical-legal education to their standards for accreditation that are annually released.

Incorporating Medical Law into Medical Education Curricula: A Literature Review

Background Traditionally, hands-on procedural training during pre-clerkship education has been limited. Students transition from the classroom to the wards with limited procedural skills. As a result, students navigate their first clerkships with anxiety about being unprepared. In response, we hosted an in-person event, the Medical School Convention (MSC), to help the first-year medical students acclimate to procedural skills they will use shortly in their core clerkship training. 

Methods An in-person targeted simulation curriculum was launched at a large, private allopathic medical school to help improve medical students' self-perceived efficacy before starting clerkships. The objective was to provide medical students with a small group, hands-on clinical and procedural skills practice to better prepare them for clinical clerkships. Six relevant skills often not included in the traditional medical school curriculum were selected for the training, each being taught at a separate station. The stations were: oral presentations, suturing, venipuncture, intubation, ultrasound, and trauma assessment. A curriculum and training course was created for each of the skills. Following the skills training, students were offered an anonymous post-survey assessing comfort and self-perceived competency with the skills taught at the stations they attended. This study was deemed exempt by the Institutional Review Board. 
Descriptive statistics were obtained for all variables. Survey responses were analyzed using paired t-tests to compare pre-training and post-training responses. A p-value of < 0.05 was considered statistically significant. 

Results In the posttest survey, 95.1% of students reported that this workshop helped them feel more confident in clinical scenarios. Additionally, 100% of students reported that they would recommend this workshop to other medical students. Although not statistically significant, there are appreciable differences in students’ perceived confidence (2.8 vs. 3.2, p=0.537) and clinical self-efficacy (5.3 vs. 6.3, p=0.998) pre-and post-training, respectively. 

Conclusion The Medical School Convention provided valuable insights regarding medical students' self-reported preparedness for the wards. Through our brief one-day course, we identified some knowledge gaps regarding procedural skills and ways to address them. We conclude that more hands-on skills training should be integrated into all medical school curricula before students begin clerkships to help increase their self-confidence.

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Next from 2022 AMA Research Challenge

Beyond the Curriculum: Equipping Medical Students to Respond to the Opioid Epidemic