United States

Background: Thrombolytic therapy is the standard of care in eligible patients presenting with acute ischemic stroke (AIS). Physicians are challenged to: 1) identify an AIS; 2) explain thrombolytic therapy; and 3) consent the patient and/or surrogate decision-maker efficiently and effectively. There is no consensus in clinician practice towards obtaining and documenting consent for thrombolytics in AIS. The objective of this study was to determine patient demographics and clinical characteristics that impact whether consent was documented for administration of thrombolytic therapy for AIS.

Methods: A multicenter mixed-methods cohort study included 442 patients who received thrombolytics for AIS. Demographics, including primary language, were collected from the electronic medical record (EMR). Code status, co-morbid dementia, stroke location, and initial NIHSS were also collected. Chi Square analysis was conducted to determine differences between two cohorts, patients who received thrombolysis and had documented consent and those who did not have documented consent in their EMR. Bivariate and multivariate regression were performed to determine associations with having documented consent. Thematic analysis was conducted on documented conversations to identify themes regarding consent for thrombolytics.

Results: The minority of patients (28.5%) had documented consent for thrombolysis in their EMR. In multivariate analysis, patients who were older (p&lt;0.001), non-white (p=0.004), primary language other than English (p=0.03), co-morbid dementia (p&lt;0.001), or had a DNR/partial code status (p=0.02) were more likely to have documented consent. Thematic analysis identified themes for documenting consent including risks and benefits, outcomes, and paternalism.

Conclusions: Documented consent was present in the minority of EMRs for patients treated with thrombolytics for AIS. Documented consent was more prevalent in populations with dementia, older age, primary language other than English, non-white, and code status. Qualitative analysis found effective consent was not documented in most cases. Given variation in consent documentation, it may be beneficial to develop standardized evidence-based language to guide these conversations.

AMA Research Challenge 2023

Documentation of Consent for Thrombolytic Therapy in Acute Ischemic Stroke

Background: Thrombolytic therapy is the standard of care in eligible patients presenting with acute ischemic stroke (AIS). Physicians are challenged to: 1) identify an AIS; 2) explain thrombolytic therapy; and 3) consent the patient and/or surrogate decision-maker efficiently and effectively. There is no consensus in clinician practice towards obtaining and documenting consent for thrombolytics in AIS. The objective of this study was to determine patient demographics and clinical characteristics that impact whether consent was documented for administration of thrombolytic therapy for AIS.

Methods: A multicenter mixed-methods cohort study included 442 patients who received thrombolytics for AIS. Demographics, including primary language, were collected from the electronic medical record (EMR). Code status, co-morbid dementia, stroke location, and initial NIHSS were also collected. Chi Square analysis was conducted to determine differences between two cohorts, patients who received thrombolysis and had documented consent and those who did not have documented consent in their EMR. Bivariate and multivariate regression were performed to determine associations with having documented consent. Thematic analysis was conducted on documented conversations to identify themes regarding consent for thrombolytics.

Results: The minority of patients (28.5%) had documented consent for thrombolysis in their EMR. In multivariate analysis, patients who were older (p<0.001), non-white (p=0.004), primary language other than English (p=0.03), co-morbid dementia (p<0.001), or had a DNR/partial code status (p=0.02) were more likely to have documented consent. Thematic analysis identified themes for documenting consent including risks and benefits, outcomes, and paternalism.

Conclusions: Documented consent was present in the minority of EMRs for patients treated with thrombolytics for AIS. Documented consent was more prevalent in populations with dementia, older age, primary language other than English, non-white, and code status. Qualitative analysis found effective consent was not documented in most cases. Given variation in consent documentation, it may be beneficial to develop standardized evidence-based language to guide these conversations.

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Stress plays a central role in functioning for all life forms. As humans, we experience stress in a multitude of ways through various types of stimuli. Due to the constancy of stressors in our lives, the nervous system has learned to allosterically adapt to the stimuli. However, when the body cannot adapt to chronic stress it can have morphological and degenerative impacts on neuroanatomy and cognitive function that may or may not be reversible. In this literature review, our aim was to identify the specific neuroanatomical structures that were impacted most by the long-term effects of chronic stress. We also describe the impact the subsequent relationship between chronic stress and the morphological changes had on cognitive function, especially on medical students. We completed our analysis through a compilation of clinical trials and other systematic reviews. Our sources were assessed on credibility and referenced from Google Scholar, PubMed, Science Direct, and NCBI. The effects of various types of chronic stress had the most impact on neurogenesis and neuronal development, brain plasticity, and spatial learning and memory with association to the hippocampus. These structures had both reversible and non-reversible morphological alterations, which also had a direct impact on the brain’s cognitive abilities. While the results and impacts of chronic stress are still being conducted, future research may be able to further highlight why stressful stimuli can particularly impact these structures and the tangential impacts that it may have on related or adjacent structures. 
Introduction
With the hustle and bustle of daily life and the constant pressures of the evolving world, chronic stress has become a commonplace occurrence. Stress is categorized as any intrinsic or extrinsic stimulus that evokes a biological response, with the compensatory responses to these stimuli labeled as stress responses (1). Stressors can have an influence and impact on psychosocial health, physiological health, and even how the body maintains homeostasis (2). While the central nervous system is primed to produce integrated coping responses, it is the autonomic nervous system that engages in the fight, flight, or coping mechanisms that help the body adjust and adapt to the stressful stimuli that it may encounter (3). Some stress responses may be instantaneous, but if the stimuli persist over a long period of time, it is generally referred to as chronic stress (3). 
How an individual reacts to the strain that long-exposed stimuli pose can potentially affect both mental and physical health, with chronic stress having a more permanent effect on the body than short term stressors (4). Additionally, the time course of stress responses can be measured by the neuroendocrine and behavioral responses from the body, which can identify how destabilizing the stimulus makes the stress manageable or harmful (1). How the stressors are processed, in turn, can have a remarkable toll on the development and functioning of the brain and nervous systems. 
The brain plays a key integratory role in processing stimuli in the adaptation to stress. Stress and stimuli are information that stimulate behavioral and physiological responsiveness between the brain and other systemic functions (4). Beyond the acute responses to stress that life may pose, allostatic load is considered to be the integral feature of chronic stress that leads to degenerative effects (5). Allostatic load includes innate and adaptive processes that help to maintain homeostasis through mediator chemical messengers like adrenaline and cortisol (6). With allostatic load comes the heightened wear and tear on the central and peripheral nervous systems and even down to the cellular level (7, 8). This systematic review aims to focus on identifying key neurological structural changes that may be induced by the effects of chronic stress and put into context how these changes may, in turn, lead to changes in behavioral or mental health as well.


The Effects of Chronic Stress on Neuroanatomy and Cognitive Function

Background:
Pregnant people face higher morbidity and mortality from influenza (flu) and COVID-19 infection than non-pregnant counterparts. Despite high vaccine efficacy, only 50% of eligible pregnant people received flu vaccine before or during pregnancy and 22% completed COVID vaccination series (including boosters) as of January 2022 and December 2022, respectively.

Objective:
Qualitatively assess how providers and nurses recommend flu and COVID vaccines during prenatal visits in obstetric practices that participated in a flu vaccine communication randomized control trial (RCT) in Rochester, NY and Los Angeles, CA.

Methods:
34 obstetric practices (21 in NY, 13 in CA) participated in an RCT to increase flu vaccination rates. 16 intervention sites received a total of 60 minutes of online training on flu morbidity, vaccine effectiveness, motivational interviewing, discussing protection of the infant, and using presumptive recommendations (“you are due for a flu vaccine”). At the end of the study, provider and nurse participants received a REDCap survey with open ended questions about how they recommend flu and COVID vaccinations during prenatal visits. Data collection occurred from July - October 2022. Investigators applied content analysis to code qualitative data into themes. Results were stratified according to study arm.

Results:
The survey response rate was 46% (124/271); and 44% (104/239) of providers and 59% (19/32) of nurses participated. For flu vaccination, increased risk of flu during pregnancy was the most common theme noted in both study arms. Intervention sites more frequently described using presumptive recommendations (14% intervention, 3% control) and normalized vaccinating (“we recommend flu vaccine for all prenatal patients”, 30% intervention, 23% control) to encourage flu vaccination. Presumptive recommendation for COVID vaccination was infrequent and occurred exclusively in intervention sites (6%). Respondents from intervention sites more often mentioned protection of the baby when discussing COVID vaccination (46% intervention, 38% control).

Conclusion:
In a qualitative analysis of flu and COVID vaccine discussions for practices that participated in a flu vaccine communication RCT, participants in intervention sites more often used presumptive recommendations and normalized vaccinating, in addition to using skills taught for flu vaccination while discussing COVID vaccination. Next steps include formally testing similar interventions to increase COVID vaccination rates for pregnant people.


Provider and nurse recommendations for Influenza and COVID-19 vaccination in obstetric practices: a qualitative analysis

Background
Due to nationwide physician shortages, many medical schools across the United States have established regional medical campuses (RMCs) to increase class size. The University of Missouri-Columbia is one such institution, creating the Springfield Clinical Campus (SCC) for third- and fourth-year students, with the first class graduating in 2018. SCC students complete their core clerkships in two community hospitals, while their central campus peers complete clerkships in a university setting. At this time, no literature exists investigating whether RMC graduates are more likely than their central campus counterparts to train in community, university, or community-based university affiliated residency programs. In this preliminary study, we compare the types of obstetrics and gynecology residency (OBGYN) programs matched by RMC and central campus graduates at the University of Missouri-Columbia School of Medicine. 

Methods
We utilized publicly available OBGYN match data from 2018-2023 for the University of Missouri-Columbia. Each residency program matched was categorized in the Fellowship and Residency Electronic Interactive Database Access (FREIDA) as university-based, community-based, or community-based university affiliated as self-reported by the programs. The Freeman-Halton extension of the Fisher exact probability test was used to calculate the two-tailed p-value comparing the proportions of students who matched at community, university, and community-based university affiliated programs.

Results
In total, 34 students who matched OBGYN from the University of Missouri-Columbia elected to make their data public. Of these, 8 students attended the SCC and 26 students attended the central campus. At the SCC, 50% of students matched at university programs, 50% of students matched at community-based university affiliated programs, and 0 students matched at community programs. At the central campus, 50% of students matched at university programs, 31% of students matched at community-based university affiliated programs, and 19% of students matched at community programs. There was no statistical difference between the campuses for the proportions of students who matched at each type of OBGYN program (p=0.4067).

Conclusion
No statistical difference between the central campus and SCC was found for the proportions of students matching at university, community, and community-based university affiliated OBGYN programs. Subsequent research including a longer timespan may be useful for elucidating trends among students training at regional versus central campuses.

A Comparison of Regional Medical Campus and Central Campus Matches into 
Obstetrics and Gynecology Programs by Type

In recent years, there has been a decline in the rates of trabeculectomy and a rise in rates of aqueous shunts and microinvasive glaucoma surgeries. , There is concern amongst glaucoma surgical educators that low trabeculectomy volumes during training are exacerbating this trend. 
The purpose of this cross-sectional survey study was to survey recently graduated glaucoma specialists and explore how surgical volume during training, success and complication rates, practice setting, and other patient population factors might influence practice patterns of recently graduated glaucoma specialists. 
A survey was distributed to the American Glaucoma Society’s “Young Glaucoma Specialists” listserv, and 66 responses were received from members completing training within the past 5 years (2018-2022). 
Sixty four respondents (93.9%) reported feeling somewhat or entirely comfortable performing trabeculectomy as a result of their training. However, 42 (63.6%) said that they do not often perform trabeculectomy, whereas only 13 (19.7%) reported that they do. 
Respondents were offered a list of factors that might influence their choice to perform trabeculectomy and selected the degree to which they agreed with each. Those who reported performing trabeculectomy often (N = 13) were influenced by the surgery’s high success rates (92.3%), its preoperative (76.9%) and intraoperative (84.6%) processes, and low postoperative complications (61.5%). Those who reported not performing trabeculectomy often (N = 42) were most discouraged by the postoperative process of trabeculectomy, as well as the socioeconomic (66.7%) and sociocultural (52.4%) characteristics of their patients. Factors such as volume performed during training (47.6%), cost-effectiveness (19.0%), and reimbursement rates (19.0%) were not considerable contributors. 

While the majority of young glaucoma specialists in our study report being comfortable performing trabeculectomy as a result of their training, the majority stated that they do not often perform trabeculectomy in practice. Notably, low trabeculectomy surgical volume during training was not cited as an notable barrier, whereas patient factors and preference for alternative procedures, depending on the clinical scenario, appeared to drive this trend.

Young Glaucoma Specialist Practice Patterns: Why do you do what you do?

Background: Clinical exposure to ophthalmology during medical school is minimal, and required ophthalmology clinical rotations have declined from 60% to 16% of Association of University Professors of Ophthalmology (AUPO)-affiliated medical schools from 2000-2018. A study evaluating medical student perception of an ophthalmology career found that “insufficient interest” and “not enough exposure” are the top reasons for not pursuing ophthalmology. Thus, there is a need to facilitate interest and exposure through extracurricular activities, such as community service. This study investigates medical students’ motivation to volunteer at a free eye clinic, prior ophthalmology exposure, and specialty interest after volunteering at Storm Eye Institute’s Fight for Sight clinic, a student and resident-run free eye clinic. 
Methods: This cross-sectional study was conducted by an online RedCap survey sent to medical student volunteers after volunteering at Storm Eye Institute’s Fight for Sight clinics between February-April 2023. Through multiple choice, open-ended questions, and Likert scales, the survey asked about demographics, prior exposure to ophthalmology, motivation to volunteer at the clinic, experience at the clinic, and career exploration. 
Results: 12 out of 18 medical student volunteers responded to the survey, representing a 66.7% response rate. Demographics revealed that most participants identified as male (75% male, 25% female) and white (67% white, 25% Asian, 8% prefer not to answer). Average exposure to ophthalmology was 4.75/10 with 0 representing no exposure, 10 representing “a lot.” 75% reported prior ophthalmology exposure as shadowing or specific subspecialty experience. The strongest motivators to volunteer were gaining exposure to ophthalmology/current residents (67%) and volunteer experience (58%). Interpreting for Spanish-speaking patients was also identified as a motivator by 25%. Participants reported a 
variety of specialities they were interested in, but the top-reported specialty was ophthalmology (identified by 83%). Average interest in ophthalmology as a career was 6.83/10 with 0 representing no interest, 10 representing “a lot,” and 67% of participants reported an increased interest after volunteering. 100% reported that they would volunteer at this clinic again. Conclusion: On average students who volunteered at free eye clinics have some prior exposure and interest in ophthalmology and are highly motivated to volunteer in order to gain exposure to ophthalmology and volunteer experience. Majority of participants had an increased interest in ophthalmology after the clinic. This study shows that free eye clinics pique interest and provide valuable career exposure to the field of ophthalmology for medical students.

Impact of a Free Eye Clinic on Medical Students’ Exposure and Interest in Ophthalmology

BACKGROUND: Artificial Intelligence (AI) generative large language models (LLMs) are powerful and increasingly accessible tools with potential applications in healthcare education and training. The annual Orthopedic In-training Examination (OITE) is widely used to assess resident academic progress and preparation for the American Board of Orthopedic Surgery (ABOS)  Part 1.

METHODS: Open AI’s ChatGPT and Google’s Bard generative language models were administered the 2022 OITE examination. Question stems that contained  images were input without, then with a text based description of the imaging findings.

RESULTS: ChatGPT answered 69.1% of questions correctly, when provided with text describing accompanying media this increased to 77.8% correct. In contrast Bard answered 49.8% of questions correctly and this increased to 58% correct when provided with text describing imaging in question stems (p&lt;0.0001.) ChatGPT was most accurate in questions within the Shoulder category with a 90.9% accuracy. Bard performed best in the Sports subspecialty category scoring 65.4% correct.  ChatGPT performed above the published mean of Accreditation Council for Graduate Medical Education (ACGME) orthopedic resident test-takers (66%.)  
CONCLUSIONS: There is significant variability in the accuracy of publicly available AI
models on the OITE. AI generative language software may play numerous potential roles in the
future assisting orthopedic education including simulating patient presentations and clinical scenarios, customizing individual learning plans and driving evidence-based case discussion.  Further research and collaboration within the orthopedic community is required to safely adopt these tools and minimize risks associated with their use.

Performance of Two Artificial Intelligence Generative Language Models on the Orthopedic In-training Examination

Background: Fellowship Directors (FDs) and Division Chiefs (DCs) have a profound impact on the current and future trainees in orthopaedics, yet no previous study has analyzed the academic, leadership, and demographic characteristics of FDs and DCs in arthroplasty. This study’s purpose was to evaluate the demographic characteristics, scholarly work, and educational training of FDs and DCs in academic orthopaedic arthroplasty divisions in the United States.

Methods: Orthopaedic arthroplasty fellowships were identified using the American Association of Hip and Knee Surgeons Directory. Data on each FD and DC was gathered via the program’s respective websites, personal profiles, curriculum vitae, and online searches. Information collected included sex, race/ethnicity, fellowship training institution, time since fellowship graduation, academic rank, additional degrees, time at current institution, time in current role, additional leadership positions held, h-index, ResearchGate score, and ResearchGate interest score. H-index was compared between FDs and DCs and the correlation between h-index and academic rank was calculated. 

Results: There were 116 FDs and 77 DCs from 137 orthopaedic arthroplasty programs included. Of these, 20 were co-FDs and 22 were both FD and DC. Overall, 98.3% were males. For race/ethnicity, 83.8% were Caucasian, 11.0% Asian, 3.5% Hispanic, and 1.7% African American. Average age in years was 52.7, years since fellowship graduation was 18.1, years at current institution was 13.9, years in current role was 9.8. Thirty had additional degrees. Average h-index, RG, and RI scores were 16.9, 27.6, and 1309.5, respectively. Overall, 29.6% were full Professor, 26.6% Associate Professor, and 23.1% Assistant Professor. There was a moderate positive correlation between academic rank and h-index. The top fellowship programs to produce future FDs and DCs were Massachusetts General Hospital (17), Hospital for Special Surgery (17) and Mayo Clinic (13). 

Conclusion: A striking lack of diversity exists in orthopaedic arthroplasty leadership, with most FDs and DCs being white males. There was a moderate positive correlation between professorship and h-index. Furthermore, there are specific fellowship programs that play an important role in producing future arthroplasty leaders. Greater efforts are needed to increase diversity among arthroplasty leadership in United States academic orthopaedic programs.

Academic, Leadership, and Demographic Characteristics of Orthopaedic Arthroplasty Leadership in the United States

Background
Gender disparities are well established in the surgical field, despite increasing prevalence of women in surgical specialties. Currently in otolaryngology, 33% of residents and 28% of faculty in academic programs are women. Women comprise 13% of full professor positions, 12% of otolaryngology program director positions, and 3.5% of otolaryngology department chair positions. Disparities in woman’s career can be seen in the manner in which they are evaluated. A public method of evaluation is through the distribution of awards. Professional awards are intended to identify and reward those that are considered the best in their field. Externally, awards are beneficial to an individual by adding more value to their resumes or curriculum vitae. Internally, these awards allow for improved self-perception and self-confidence. This study aims to evaluate gender disparities in otolaryngology residency training with a focus on awards in residency.

Methods
122 OHNS training programs were sent emails with a survey link requesting participation. Questions including number of women residents as well as questions pertaining to specific awards were detailed. Primary outcome measures were total number and percentages of awardrecipients that were women. Further analysis stratification was completed for geographic location and award type.

Results
15% of programs contacted participated in our survey. Data was gathered from 2010-2019. The percentage of women in a given OHNS residency program ranged from 0% to 55%. Awards distributed to women in a program ranged from 6% to 50%. Women were disproportionately awarded in all residency program except one, in which they were over-awarded. Overall, women were found to be 42% less likely to receive a residency award compared to men (OR, 0.58; 95% CI, 0.42 to 0.81; P = 0.001). Statistical significance was identified in awards of academic excellence, where women residents were found to be 54% less likely to receive an award, as well as in teaching awards, where women were 51% less likely to receive an award. When addressing whether the responder believed gender bias existed in otolaryngology residency, 58% felt there may be some bias, while 24% responded yes, and 12% responded no.

Conclusion
Gender inequalities exist at several stages within an individual’s academic career including at the resident trainee level. This study demonstrates that women are disproportionately distributed residency awards when compared to their male colleagues in OHNS. Knowledge of these disparities must be made to prevent a negative long-standing impact on women residents within OHNS programs.

Gender Disparities in Otolaryngology-Head and Neck Surgery Residency Awards

Background D/deaf individuals are at risk for poor health outcomes compared to their hearing counterparts due to communication and cultural differences. Given the high prevalence of hearing loss, health professionals and trainees should be aware of this issue. DEAFMed is a novel educational program designed to address these topics. We hypothesized that this program would effectively introduce health professions students to Deaf culture and how to communicate effectively with patients with hearing differences to improve their delivery of equitable care.
Methods In its pilot year, this prospective cohort study included 98 health professionals and trainees across medicine, occupational therapy, and nursing at a single institution. Participants attended up to five 90-minute seminars that discussed Deaf culture and American Sign Language (ASL). Participants took pre- and post-intervention surveys to assess changes in attitudes and beliefs. Incentives for participation included remote access via Zoom, free food, and medical humanities course credit. Primary outcomes included comfort in approaching care of the D/deaf patient and awareness of common misbeliefs about the community. Results were analyzed using descriptive statistics and Wilcoxon matched-pairs signed rank tests.
Ó 2023 American Medical Association. All rights reserved.
Results Only one lecture was found to have statistically significant changes in participant attitudes and beliefs (p = 0.03). The lack of statistical significance between pre- and post- intervention is likely due to an insufficiently powered cohort. However, on a scale of 1 (strongly disagree) to 5 (strongly agree), participants consistently agreed that the medical school should offer more formal programs addressing health care and D/deaf people (4.66±0.16) and that the experience is likely to positively impact attitudes and behavior in future interactions with all patients with limited English proficiency or alternative primary communication modalities (4.46±0.18). Furthermore, participants’ responses indicated that they felt more comfortable in their understanding of Deaf culture because of their participation in DEAFMed (4.20±0.16).
In the upcoming academic year, the DEAFMed programming will expand to include more opportunities for attendees to learn and practice ASL during every session to bolster engagement.
Conclusion Overall, the results suggest a positive response to the DEAFMed pilot and support the feasibility and importance of replicating this intervention in medical education. Future interventions with dedicated communication exercises in English and ASL are expected to enhance engagement.

DEAFMed: Deaf Education and Awareness for Medical Students

There appears to be an association between musculoskeletal (MSK) symptoms and computer use leading to sick leave, efficiency loss, and work-related sickness (Oha 2014, Khan 2012). Earlier studies by Bernard et al in 1994 found a dose-response relationship between the duration of computer work and musculoskeletal complaints. In 2012 musculoskeletal disorders were responsible for 34% of all workplace injuries and illnesses and cost $45-54 billion to the US economy (Bureau of Labour Statistics 2014, National Research Council 2001). 

Laptop use specifically has been steadily increasing since 2005-52.8%, 2007-75.8% (Jacobs 2009), and in 2014, 95.4% of University students reported using a laptop (Dockrell 2015). The laptop's "face down forward head posture" may compromise the resting spinal columns' double "S-shape" affecting the entire spine and neck (Annetts 2012, Toosizadeh 2012) including lumbar and pelvic areas which allow stability during sitting (Annetts 2012). 

The mass of the head falls in front of the center of gravity for the C-spine which passively stretches ligaments and joint capsules resulting in chronic neck pain (turtle neck posture, text neck) (Cho 2008). This chronic stress may lead to prominent exostosis projecting from the occipital squama (Shahar 2018).

Medical Residents at The Wright Center for Graduate Medical Education are involved in high-intensity medical management of patients in our FQLA facility and the standard tools used in the facility are laptops that are signed in, and out daily and used at home. This RCT trial randomizes a laptop stand, USB mouse, and keyboard to determine if there is an effect on MSK pain using a modified NORDIC questionnaire combined with a Visual Analogue Scale distributed via Google Docs at baseline, 3 months, and 6 months involving half of the incoming first-year residents in Family Medicine, Internal Medicine, Physical Medicine and Rehab and Psychiatry (n=57).


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Next from AMA Research Challenge 2023

The Effects of Chronic Stress on Neuroanatomy and Cognitive Function