United States

Background 
Due to the harmful effects of unmet social needs on patient health outcomes, professional societies currently recommend providers in all healthcare settings screen patients for social risk factors. Unfortunately, current literature shows that patients with social risk factors have difficulty accessing primary care and have increased preventable emergency care utilization. Limited research is available to determine if ambulatory clinics adequately capture vulnerable populations. This study compares the prevalence of social risk factors among patients screened in primary care clinics to the prevalence of those factors in Connecticut in general to determine if vulnerable populations are receiving ambulatory care.

Methods 
Researchers reviewed data from screenings performed from 9/13/2021 to 5/6/2022 at 3 primary care clinics in Connecticut. Volunteers screened patients for social risk factors using the Protocol for Responding to and Assessing Patients’ Assets, Risk, and Experiences assessment tool. To determine the screening’s effectiveness; the measured prevalence of unemployment, food insecurity, low educational attainment (no GED equivalent), utilities stress, homelessness, and decreased English fluency was compared to state-wide prevalence of those factors. Investigators determined the state-wide prevalence of utilities stress and homelessness through finding the proportion of the population that received CT Energy Assistance Program benefits or contacted the CT Coordinated Access Network in need of housing assistance. Government data published between 2019 and 2021 provided the prevalence of all other factors. Researchers compared the prevalences using Chi-Square Tests of Independence with a p-values of &lt;0.05.

Results
Volunteers screened 2,150 patients. Analysis found no significant difference between the state-wide prevalence of educational attainment (8.9% vs. 8.7%, p=0.79), utility stress (5.8% vs. 5.7%, p=0.87), food insecurity (4.2% vs. 4.7%, p=0.21), and decreased English fluency (10.0% vs. 10.3%, p=0.61) and the prevalence of those factors among patients screened. Patients screened had a significantly higher prevalence of unemployment (9.2% vs. 6.3%, p&lt;0.05) and homelessness (3.0% vs. 1.3%, p&lt;0.05) compared to the state overall.

Conclusion 
Although current literature shows that vulnerable populations experience barriers to receiving primary care and have increased utilization of emergency care, our study found that the prevalence of social risk factors among patients seen in ambulatory clinics was similar to, if not higher than, the prevalence of those factors in the state overall. This indicates that ambulatory clinics adequately capture vulnerable populations. Results argue that the screening performed was effective in identifying social risk factors and that ambulatory clinics could be an adequate site for targeted interventions. Generalizability of these results to other states, pediatric populations, and specialty clinics may be limited as the screenings reviewed were performed with adults at primary care clinics in Connecticut.


2023 AMA Research Challenge

Social Determinants of Health Screening Demonstrates that Vulnerable Populations Do Receive Ambulatory Care

Background 
Due to the harmful effects of unmet social needs on patient health outcomes, professional societies currently recommend providers in all healthcare settings screen patients for social risk factors. Unfortunately, current literature shows that patients with social risk factors have difficulty accessing primary care and have increased preventable emergency care utilization. Limited research is available to determine if ambulatory clinics adequately capture vulnerable populations. This study compares the prevalence of social risk factors among patients screened in primary care clinics to the prevalence of those factors in Connecticut in general to determine if vulnerable populations are receiving ambulatory care.

Methods 
Researchers reviewed data from screenings performed from 9/13/2021 to 5/6/2022 at 3 primary care clinics in Connecticut. Volunteers screened patients for social risk factors using the Protocol for Responding to and Assessing Patients’ Assets, Risk, and Experiences assessment tool. To determine the screening’s effectiveness; the measured prevalence of unemployment, food insecurity, low educational attainment (no GED equivalent), utilities stress, homelessness, and decreased English fluency was compared to state-wide prevalence of those factors. Investigators determined the state-wide prevalence of utilities stress and homelessness through finding the proportion of the population that received CT Energy Assistance Program benefits or contacted the CT Coordinated Access Network in need of housing assistance. Government data published between 2019 and 2021 provided the prevalence of all other factors. Researchers compared the prevalences using Chi-Square Tests of Independence with a p-values of <0.05.

Results
Volunteers screened 2,150 patients. Analysis found no significant difference between the state-wide prevalence of educational attainment (8.9% vs. 8.7%, p=0.79), utility stress (5.8% vs. 5.7%, p=0.87), food insecurity (4.2% vs. 4.7%, p=0.21), and decreased English fluency (10.0% vs. 10.3%, p=0.61) and the prevalence of those factors among patients screened. Patients screened had a significantly higher prevalence of unemployment (9.2% vs. 6.3%, p<0.05) and homelessness (3.0% vs. 1.3%, p<0.05) compared to the state overall.

Conclusion 
Although current literature shows that vulnerable populations experience barriers to receiving primary care and have increased utilization of emergency care, our study found that the prevalence of social risk factors among patients seen in ambulatory clinics was similar to, if not higher than, the prevalence of those factors in the state overall. This indicates that ambulatory clinics adequately capture vulnerable populations. Results argue that the screening performed was effective in identifying social risk factors and that ambulatory clinics could be an adequate site for targeted interventions. Generalizability of these results to other states, pediatric populations, and specialty clinics may be limited as the screenings reviewed were performed with adults at primary care clinics in Connecticut.

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Background: Many medical schools have begun including health systems science (HSS) in their curricula to address emerging healthcare needs. With this principle in mind, a clinical reasoning exercise was developed by the Johns Hopkins neurology clerkship team in 2017. Students are given a standardized case of a patient presenting with falls and asked to develop an assessment & plan. During the COVID-19 pandemic, Johns Hopkins replaced tiered grading (honors/high pass/pass/fail) with pass/fail grading for core clerkships. This study seeks to determine if clerkship grading (tiered versus pass/fail) influences the quality of the differential diagnoses, localization of the disease process, clinical reasoning, and diagnostic/management options.

Methods: Data was extracted from the case reports submitted by students in the Neurology clerkship between 2017 and 2022. Report elements in tiered versus pass/fail curricula were compared using chi-squared tests.

Results: Of the 592 students, 306 (51.7%) were in the tiered curriculum, and 286 (48.3%) were in the pass/fail curriculum. With respect to differential diagnoses, students were more likely to include drug-induced parkinsonism (p<0.05) in the tiered system, and Lewy body dementia (p<0.05) in the pass/fail system. The inclusion of other diagnoses was not significantly different between the two systems. For localization, students were more likely to localize to the substantia nigra specifically (p<0.05) in the pass/fail compared to tiered system. Clinical reasoning elements like dysautonomia and timing (p<0.05) were cited more in the tiered system, while discussion of REM sleep behavior was not significantly different between the two systems. Students were more likely to order labs but less likely to order imaging (p<0.05) in the tiered versus pass/fail system. Lastly, for management, students were more likely to request outside consultations/referrals, initiate physical therapy, stop metoclopramide, and treat urinary symptoms and hypotension (p<0.05) in the tiered versus pass/fail system. Treatment with carbidopa-levodopa did not significantly differ between the two systems.

Conclusion: Although clerkship grading does not appear to influence differential formation or clinical reasoning strongly, it does influence diagnostic testing and management choices. Tiered grading correlates with aspects of HSS, including value-based care (deferring imaging, stopping metoclopramide) and interprofessional collaboration (consults, physical therapy).

Looking Backwards to Look Forward: An Analysis of Clinical Reasoning Reports in the Neurology Core Clerkship before and after the transition to Pass/Fail Grading

Background: While most births in the U.S occur in a hospital, out-of-hospital births have been increasing in popularity with one in every 61 births occuring at home or in a community birthing center. The fear of disrespect and loss of autonomy have been cited as primary drivers for planned home births with data showing higher rates of mistreatment occurring in hospital settings than at home. This was especially apparent for individuals who transferred from a community setting to the hospital after the onset of labor. Approximately 10% of home births will experience transfer to a hospital due to urgent and non-urgent reasons. Despite this, there are still no standardized guidelines for managing home birth transfers to hospital care which can lead to delays in receiving care. Additionally, there have been reports of significant opposition to home births among hospital-based clinicians (HBCs) which negatively impacts the birthing person’s experience with hospital births. 

Washington’s Smooth Transitions™ Quality Improvement Program aims to better understand the perceptions of birthing persons on transfers from planned community births to hospitals in order to identify barriers and areas of improvement. 

Methods: Smooth Transitions distributed an online mixed-methods survey to birthing persons upon discharge to capture lived experiences of home to hospital birth transfers in 17 Washington-based hospitals. Free response questions inquired about quality of care, overall birthing experience, and collaboration between the birthing care team. The data was coded for thematic content to identify best practices and potential areas of improvement.

Results: A total of 190 birthing persons completed the survey. 18% of these respondents felt that their personal preferences were not respected by the HBCs and 21% felt pushed into agreeing with care options. Birthing persons valued the HBCs respecting their autonomy, birth plan, and support team. Areas of improvement included shorter check-in times, allowing the community midwife to be present and more involved in care plans, and better patient education provided by the HBCs.

Conclusion: Birthing persons’ perceptions of transfers help us better understand opportunities for improving their experience with hospital births. Respondents self-reported various levels of disrespect, lack of autonomy, and inadequate informed consent by HBCs which were exacerbated by patient-provider disagreements around care plans. Further efforts need to be made to understand and reconcile the goals of care for HBCs, patients, and their support team. This will help to create a best practices guideline for these transfers and improve maternal and fetal health outcomes.

Patient Perceptions on Transfers from Planned Community Births to Hospital care in Washington State

Inappropriate Administration of Mitomycin in Cataract Patient

Background
This study describes the unintended intracameral administration of the chemotherapeutic agent mitomycin following a cataract extraction. The operating physician intended to use cefuroxime (antibiotic); however, mitomycin was used instead due to an intraoperative mishap, leading to permanent vision loss.

Case Presentation
An 83-year-old male seen in the clinic for an eye exam was found to have visually significant bilateral cataracts. Vision in the right eye (OD) was 20/80, and vision in the left eye (OS) was 20/70. He subsequently underwent technically uncomplicated cataract surgery in the right eye.

At postoperative visit one, vision was 20/250 OD, less than anticipated for unclear reasons. On subsequent visits, the patient was found to have worsening photophobia, increasing conjunctival inflammation, corneal edema, and an elevated intraocular pressure of 27mmHg. There was also worsening corneal edema and an exacerbation of intraocular inflammation. Given the variety and complexity of symptoms despite an otherwise uncomplicated surgery, an investigation was launched at the surgery center.

Discussion
The investigative report found the cause of the patient's postoperative symptoms to be unintentional intracameral mitomycin administration. In this case of mitomycin-induced ocular insult, the surgery center kept both chemotherapy drugs and antibiotics in refrigerators that were proximate to one another. The wrong medication had circulated through three different hands, eventually being injected into the patient's eye without knowledge. 

Since this event, the surgery center has moved the medication housing the chemotherapeutic agents to a different part of the building and added extensive colored labeling. Implementing a scanning system may have prevented this injury by prohibiting the nurse from withdrawing a particular medication if not ordered by the surgeon. There may also be reasons to evaluate the concurrence of fatigue associated with errors. Enforcing verbal repetition for orders may also help reduce the misadministration of medications.

In this case, a system failure led to the misadministration of the mitomycin. Rather than focusing on the inability to precisely diagnose chemotherapeutic agent toxicity, in a reactive analysis, there should be aims to promote a system where there is no error or the error is overtly obvious. This case serves to illustrate that instead of assigning human blame, system changes are necessary to reduce medical errors in order to give patients the care they deserve while minimizing risk to their health.

The Cataract Conundrum

Background:
Deciding when a patient is a candidate for Total Hip (THA) or Knee (TKA) Arthroplasty to treat arthritis is complex. Accordingly, shared decision-making (SDM) between patient and surgeon regarding candidacy for THA/TKA is considered best practice. However, successful SDM requires clear communication of specific symptoms, their individualized functional impact, and a mutual understanding of expectations. Understanding a patient’s perspective and where communication gaps may occur can improve this conversation. The OPTION (Objective Performance Threshold Indicating Operative Need) Survey was developed to guide SDM regarding readiness for THA/TKA. Survey results provide critical insights into this conversation: specifically, surgeon perception of the patient’s experience, how individual patient priorities differ in arthritis management, and how radiographic data align with patients’ symptoms. 
Methods:
The OPTION survey was created in partnership with a panel of 10 active THA/TKA patients and 10 arthroplasty surgeons using a modified Delphi methodology that employed three sequential meetings with each group. It interrogates patient-reported pain VAS, activity limitation, duration of treatment, prior treatments, quality of life (QOL), treatment priorities, patient readiness for surgery, and xray changes. As an IRB- approved pilot, OPTION criteria surveys were completed during 643 patient-surgeon encounters discussing TKA/THA candidacy at 15 clinical sites in the US. Each OPTION survey was independently and anonymously completed by the patient before the encounter and verified by the surgeon after the encounter. 
Results:
Within each domain, there was disagreement in patient and surgeon response in less than 10% of cases. With questions of pain VAS, activity limitation, and QOL, where surgeon and patient responses differed, the surgeon most often understated the patient’s reported subjective experience. Higher patient prioritization of pain relief, minimizing activity limitation, and avoiding medications directly correlated with readiness for surgery. Avoiding high cost was consistently the lowest patient priority across groups; cost prioritization dropped most substantially once QOL was impacted. Surgeon-graded radiographic joint space narrowing correlated with patient-reported QOL impact and readiness for surgery. While early joint space loss was seen with mild activity limitation and pain, a ceiling effect was evident with respect to joint space narrowing as pain and activity limitation increased. 
Conclusion:
- When patient and surgeon disagree, surgeons tend to underestimate the patient- reported experience of arthritis. 
- Patient priorities in arthritis treatment vary depending upon the individualized functional impact of various factors on their personal experience. 
- Radiographic joint space narrowing does not reflect the full picture of the patient experience with arthritis. 


Incorporating Patient Preferences into the Science of Shared Decision-Making for Discretionary Surgery: Understanding Surgeon and Patient Perspectives Regarding When it is Time for Elective Total Hip or Knee Replacement

Background: The impact of socioeconomic status (SES) on health outcomes is an increasingly important topic. Identifying which patients are more likely to present with advanced musculoskeletal pathology is a top priority. The Area Deprivation Index (ADI) ranks neighborhoods across the United States based on socioeconomic disadvantage. The Childhood Opportunity Index 2.0 (COI 2.0) measures community resources and ranks neighborhoods according to the social determinants of health. Our study aimed to determine the relationship between scoliosis curve magnitude at presentation and SES as measured by the ADI and COI 2.0.

Methods: We retrospectively identified 1,649 patients presenting for adolescent idiopathic scoliosis at a single academic center between June 27, 2018 and June 6, 2023. The patients were divided into a non-surgical and surgical cohort with 1,510 and 139 patients, respectively. Curve magnitude at initial presentation (Cobb angle), BMI, and address were recorded using the electronic health record. Patients’ addresses were used to determine their ADI and COI 2.0 scores. The information was assessed using univariate analysis.

Results: Patients in the surgical cohort were more likely to have a higher ADI National Percentile, higher ADI State Decile, higher BMI, and greater Cobb angle at presentation compared to the non-surgical cohort (p = <0.05). Within the surgical cohort, patients with a higher BMI were more likely to have a greater Cobb angle at initial presentation (p = <0.05). Within the non-surgical cohort, patients with a Cobb angle >45 were more likely to have a higher ADI State Decile and live in neighborhoods with a higher poverty rate compared to patients with a curve <45 (p = <0.05). Within the non-surgical cohort, patients with a Cobb angle >45 were more likely to live near hazardous waste dump sites compared to patients with a curve <45 (p = <0.05).

Conclusion: There are significant associations between SES and scoliosis curve magnitude at presentation. Patients that have undergone surgery are more likely to be socioeconomically disadvantaged at a state and national level, according to the ADI. Non-surgical patients with a greater amount of socioeconomic disadvantage at the state level, those who live in neighborhoods with higher poverty rates, and those with greater environmental pollutant exposure are more likely to present with a Cobb angle that exceeds bracing indications (>45). More work must be done on a state and national level to identify, treat, and educate socioeconomically disadvantaged patients before their curve magnitude exceeds non-operative management.

The Impact of Socioeconomic Status on the Magnitude of Scoliosis Curve at Initial Presentation

Patient-reported outcomes (PROs) are increasingly recognized as a valuable data source that captures a patient’s experience of their disease, yet routine clinical PRO collection is still uncommon. We sought to understand the barriers and facilitators to sustainable PRO collection in an outpatient musculoskeletal practice. We performed a formal root-cause analysis and separated identified issues into three categories: technical, process, and human. We developed a multipronged intervention to target root causes. Qualitative feedback from patients and staff suggested that these changes resulted in more streamlined workflows and increased satisfaction.

Optimizing patient-reported outcome collection in a musculoskeletal outpatient clinic setting

Background

The Resource-Based Relative Value Scale (RBRVS) is utilized by the Centers for Medicare & Medicaid Services (CMS) and private payers alike to determine fee for service physician reimbursement. RVUs incorporate clinical and nonclinical resources, expertise required, and physician effort. Studies have demonstrated durable differences in RVUs for lumbar fusion instrumentation, but there has been no study on RVU reimbursement in cervical spine fusion. This study aims to compare mean work RVUs (wRVUs), mean operative time (OpTime), and wRVUs/min in single and multi-level anterior (ACDF) and posterior (PCDF) cervical decompression and fusions performed between 2011 and 2020.
Methods

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for Current Procedural Terminology (CPT) codes. CPT code 22551 reflects a primary ACDF level and subsequent 22552 codes correspond to additional levels while 22600 reflects a primary PCDF level and subsequent 22614 codes correspond to additional levels. The cohort was stratified into 5 groups: single-level, 2-level, 3-level, 4-level, and 5+ level anterior and posterior cervical fusions. Mean operative times, mean wRVUs, and wRVU/min were calculated and compared by the heteroscedastic student’s t-test.
Results



100,997 patients who underwent cervical fusion met the criteria for inclusion in this study in the following cohorts, with the vast majority receiving 1 and 2 level fusions. In single-, 3-level, 4- level, and 5+ level fusion, the anterior approach demonstrated significantly lower mean wRVU (p<0.001). Interestingly, an anterior approach demonstrated higher mean RVU for a 2-level fusion (67.76 ± 14.72 vs 65.98 ± 23.02, p<0.0001) over the study period. In single-, 2-, 3-, and 4-level fusion the anterior approach had significantly lower OpTime (all p<0.001). The anterior
approach also demonstrated significantly higher wRVU/min in single- and 2-levels (p<0.001) but lower wRVU/min in 3- and 4-level fusions ( p<0.001). No differences were seen in OpTime or wRVU/min between anterior and posterior approach for 5+ level fusions (p>0.05).
Conclusion

For single through 4 level fusions, anterior approach demonstrated lower OpTime and higher wRVU/min for single and 2-level fusions. As the number of fusion levels increased to 3- and 4- levels, wRVU/min was higher for posterior approaches. At 5+ levels, these returns became indistinguishable. These results may guide individual practices as spine surgeons aim to optimize surgical quality and outcomes as health services reimbursement shifts toward value based bundled reimbursements.

Comparison of Relative Value Unit (RVU) reimbursement anterior or posterior cervical spinal fusion

Introduction/purpose: 
Increased access to the internet and subsequent utilization of online health education materials by patients have established a demand for formal appraisal of such resources. The aim of this study was to evaluate the quality, credibility, and readability of web-based information related to turbinoplasty.

Methods: 
Search terms including “turbinoplasty nasal surgery”, “turbinate reduction”, “turbinate surgery”, and “nasal conchae surgery” were used to perform a search on Google.com, Bing.com, and Yahoo.com. Within each search term used, the top 30 results from Google.com were assessed, while the top 10 and top 5 results were assessed from Bing.com and Yahoo.com, respectively. The webpages were separated by authorship classification into six distinct groups: academic, commercial, governmental agency, health information platform, professional society, or other. To assess web page readability, the Flesch-Kincaid grade level, Gunning-Fog Index, SMOG Index, and Coleman-Liau Index were utilized. Webpage quality was computed through the DISCERN Instrument (DISCERN), the Journal of the American Medical Association benchmark criteria (JAMA), Novel Turbinoplasty Index (NTI) and presence of code certification by Health on The Net (HON).

Results: 
A final count of 71 unduplicated text-based web pages were appraised. Information quality was measured by an average DISCERN score of 47.4±7.40, indicating “fair” quality according to the scoring bands. The average readability was 9.7±1.57, notably higher than both grade level readability recommendations from either the American Medical Association (AMA) or National Institutes of Health (NIH). Of all web pages, only 11 (15.49%) proficiently met all four listed JAMA criteria. Significant correlations between web page classification and average DISCERN (p = 0. 0042) as well as JAMA score (p < 0.001) were discovered. The web pages that had HON code certification revealed significantly higher quality metrics with higher DISCERN scores (p < 0.001), JAMA scores (p < 0.001) and NTI scores (p = 0.038).

Conclusion:
Online health information associated with turbinoplasty has a considerably “fair” quality, while the average readability is several grade levels above the current AMA and NIH recommendations. Healthcare professionals should be encouraged to instruct their patients on proper search techniques for high-quality health resources on the web, as well as provide these materials in a physical written format when appropriate. We also recommend that health-based web pages amend their published information in a manner which can more effectively reach their intended consumers without sacrificing quality.

Quality and Readability Analysis of Turbinoplasty on the Web

Objective
To develop an evaluation clinic for toddlers suspected of having autism spectrum disorder (ASD) that improves the efficiency of the evaluation process and care coordination for those diagnosed with ASD. 

Purpose
While most children in the U.S. (85%) identified with ASD had documented caregiver concerns about their development by 3 years of age, less than half received an evaluation before their 3rd birthday.1 In addition, after receiving a diagnosis of ASD, many families struggle to connect with the recommended services and caregiver understanding of common features of ASD can be limited. MIND Institute staff recognized the need to develop a streamlined process to evaluate young children referred for ASD and assist families with navigating services. 

Methods
Children ages 15 to 42 months at time of referral for concern of ASD were triaged to the clinic. A licensed clinical social worker (LCSW) completed a telephone intake with families prior to the evaluation to explain the nature of the clinic and complete a structured interview inquiring about developmental milestones and behaviors concerning for ASD. The in-person evaluation consisted of an Autism Diagnostic Observation Schedule 2nd Edition, and the Bayley Scales of Infant and Toddler Development 4th Edition (BSID-4) cognitive subtest or the Differential Ability Scales 2nd Edition (DAS-II). The BSID-4 and DAS-II were not completed if either developmental assessment was recently completed and documented in the electronic health record. If the patient was diagnosed with ASD, caregivers met with a LCSW to discuss next steps in service coordination and were referred to the UC Davis MIND Institute Caregiver Coaching and Family Navigator programs.

Results
Since the clinic started in August 2022, 29 children ages 19 to 49 months (23 M, 6 F) have received an ASD evaluation. One appointment was rescheduled, and none were canceled. The average time from referral to evaluation was 5 months. Twenty-five children (86%) were diagnosed with ASD; 16 (64%) of these families were referred to the Family Navigator program. Twenty-one of the 29 families were insurance eligible for the Caregiver Coaching program; of those, 4 (19%) have been enrolled and 12 (57%) are pending enrollment. 

Conclusion 
Preliminary data suggests that structured intakes completed by a LCSW prior to and service coordination after an initial ASD evaluation can improve clinic show rates and engagement in services. 


A Clinic Model for Evaluation and Care Coordination for Toddlers Suspected of Having Autism

Background: To assess school-aged children’s wellbeing and to characterize changes in school-related needs from 2021 to 2022.
Methods: We surveyed a nationally representative sample of parents of children enrolled in grades K-12 in the 2021-2022 academic year in June 2021 and again one year later (June 2022). Parents completed the Strengths and Difficulties Questionnaire (SDQ) and reported their child’s general health and needs for school-related services. Weighted regressions examined associations among wellbeing, needs, and socio-demographic characteristics.
Results: 1,504 participants completed baseline and 1,199 completed follow up surveys. The percentage of children with deficits in total difficulties, hyperactivity, and prosocial behavior decreased from baseline to follow up, but a high percentage of children continued to have peer problems. Parents reported receiving support from their school for 45.3% of needs during the 2021-2022 school-year but 72.5% of parents continued to have at least one school-related need. Highest priority needs were academic enrichment, socialization, physical activity, tutoring, and coping with stress.
Implications for School Health Policy, Practice, and Equity: While many children with school-related needs received school support, a large percentage continue to have unmet needs and experience peer-related problems.
Conclusions: Continued investment in school-based services is necessary to support child health.

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Social Determinants of Health Screening Demonstrates that Vulnerable Populations Do Receive Ambulatory Care

Next from 2023 AMA Research Challenge

Looking Backwards to Look Forward: An Analysis of Clinical Reasoning Reports in the Neurology Core Clerkship before and after the transition to Pass/Fail Grading