United States

Background: The Standardized Patient (SP) Program is a potential avenue through which ethnic minority medical students experience bias, due in part to the inherent subjectivity of an SP’s evaluation of the doctor-patient interaction (DPI). In most training programs, medical students are assessed on their clinical and interpersonal skills via simulated encounters where students assume the doctor role and SPs act as patients. Previous multi-institutional research showed that African American students received a lower group performance score than white students when evaluated by SPs on interpersonal skills. Subsequently, this may result in differential attainment, a phenomenon where graduates of underrepresented backgrounds become subject to worse outcomes during residency selection and specialty training. This qualitative study unprecedentedly compares the perspectives of ethnic minority medical students with that of SPs in the context of DPI. We additionally sought to identify areas within the SP Program that may perpetuate bias and ultimately impact the minority student experience.
Methods: Participants were recruited from a single U.S. allopathic medical school. A total of 14 medical students from the second-year class, 11 of which self-identified as non-white ethnic minorities, were distributed into 6 focus groups. A total of 9 SPs were interviewed, 3 of which self-identified as non-white ethnic minorities. All interviews were then transcribed and analyzed using a combination of first-cycle coding methods in NVivo. In the final stages, we examined the data to determine frequent themes across the study populations.
Results: The results demonstrated conflicting sentiments between SPs and students. Although SPs described an intensive training process that promoted standardization of DPI scoring across SPs, ethnic minority students reported high interSP variability, referring to the variation in the interpretation of a student’s communication skills by SPs. The consensus amongst minority students was that SPs evaluate students more leniently in interactions where the SP and student share ethnic identities. Students endorsed a constant internal awareness of their ethnicity during these simulated encounters as a consequence. In particular situations, that awareness pressured students into altering their personality in order to receive evaluations comparable to their white colleagues.
Conclusion: Although medical education administrators have begun shifting their attention towards diversity, equity, and inclusion initiatives, there has been minimal focus on the key perspectives necessary to navigate this space. Our research analyzes those perspectives as an important first step towards acknowledging and effectively mitigating bias in medical education programs. Next steps involve restructuring the SP training process to incorporate unconscious bias training.

AMA Research Challenge 2023

Two Sides to Every Story: Comparing Perspectives of Ethnic Minority Medical Students and Standardized Patients

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This study evaluated the Collaborative Approach to Learning Medicine (CALM) program at Rutgers New Jersey Medical School, a peer-to-peer educational support initiative for first-year medical students. A pre-post study was conducted in the 2022-2023 academic year, analyzing survey responses from 47 participants. Pre-survey results indicated students' perceptions of the program, with question banks being the most effective resource (mean score: 4.2) and student-led tutoring as the least effective (mean score: 3.5). After participation, the effectiveness of overview sessions, review sessions, and anatomy course videos significantly increased (p<.05). Qualitative feedback emphasized improving question quantity and quality. This study highlights the CALM program's effectiveness in peer-to-peer teaching while recommending resource allocation to enhance frequently used components.

Perceptions of Medical Students Towards the Effectiveness of the Collaborative Approach to Learning Medicine Program

Background
Given increasing competition for residency positions and emphasis on USMLE performance in residency application evaluation, medical students must often prioritize studying for the USMLE over other responsibilities. There has been an explosion in the number and availability of USMLE test preparation resources over the past two decades as students use these resources for board exam preparation and as a supplement to their medical school curriculum. With increased pressure to excel in both school and board exams, these resources have become an increasingly valuable, yet expensive necessity for students. To date, comprehensive review of the number of students using third-party resources across multiple-institutions has not been performed. This systematic review aims to determine the commercial third-party resources used by medical students as supplements to the standard medical curriculum or as aids in USMLE board exam preparation.
Methods
A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy designed by a medical librarian was used to retrieve articles from Embase.com, Ovid-Medline All, Scopus, Web of Science, and ERIC (ProQuest). Inclusion criteria was original research articles centered in US medical schools that included information on student use of third-party commercial resources. The meta-analysis was performed for resources that had a minimum of three studies investigating student use of that resource. Effect size was computed for each study and a pooled effect summary with 95% confidence intervals was calculated to summarize across studies.
Results
A total of 1056 citations were screened with 19 full-text studies included in this review. Of these, 21% had a study population comprised of osteopathic medical students, 79% had a study population comprised of allopathic medical students, and 5% was comprised of both. 22 unique third-party resources were examined across all studies, with meta-analysis revealing the three most common commercial resources used by medical students to be First Aid, UWorld, and Pathoma with effect summaries of 78.22% (39.20%-117.23%), 75.96% (53.61%-98.31%), and 63.64% (36.86%-90.42%) respectively. 
Conclusion
In this systematic review and meta-analysis, we synthesized findings from 19 different studies investigating the use of 22 commercial third-party resources by medical students with the most popular being First Aid, UWorld, and Pathoma. In light of the widespread utilization of third-party resources, medical faculty should consider adapting their curriculum to better cater to the learning needs of students and establish systems that ensure equitable access to verified commercial resources.

Unlocking Medical Student Success: A Systematic Review and Meta-Analysis of Third-Party Resources Used as Supplements for Medical Education and USMLE Board Preparation 

Background
Imposter Phenomenon (IP) involves a pattern where individuals doubt their skills and worry they will be exposed as frauds. Students who experience IP tend to discount positive feedback and their accomplishments. Furthermore, IP predisposes to depression, anxiety, and suicidal ideation. Of concern, the estimated prevalence of IP in medical students ranges from 22.5%-46.6%. Despite this, there is scant empirical literature exploring IP in clinical medical students. The few studies that exist suggest that aspects of medical education may contribute to IP, but there is currently little longitudinal data exploring this. Therefore, the purpose of this study is to assess IP in third-year medical students prior to and after clerkships. 
Methods
A single class of medical students was surveyed immediately prior to (Time 1) and after clerkships (Time 2) using the Clance Imposter Phenomenon Scale. Data was analyzed using Wilcoxon signed-rank tests to determine significant differences in IP. After Time 2, students participated in semi-structured interviews to assess their personal experiences with IP. Interviews were conducted using a predesigned interview guide consisting of nine open ended questions. Thematic analysis was performed to determine protective and contributing factors to IP. 
Results
Of the 141 students, 18 students took both surveys and 10 participated in semi-structured interviews. There was no statistically significant difference in IP scores (p=0.970), with scores indicating “frequent imposter feelings”. Thematic analysis of student responses revealed protective factors such as increasing confidence, safe learning environments, and role model/peer interactions. Contributing factors included making comparisons to other students, perceived knowledge gaps, and evolving/new stressors. 
Conclusion
Medical students in our study reported frequent imposter feelings, with no significant difference in scores. These scores are comparable to other studies examining IP during clerkships. Students in our study suggested that while they built confidence in the clinical domain, other stressors elicited feelings of doubt and imposterism, such as upcoming board exams. Furthermore, comparisons to other students and perceived knowledge gaps can elicit these feelings. Despite this, students found that conversations with mentors and peers can build comradery and reduce feelings of IP. As other studies have noted, institutional culture is important. Students in our study suggested that preceptors who create a safe learning environment helped reduce IP feelings. Institutions may benefit from encouraging this type of dynamic, while also creating opportunities for students to build comradery during clerkships. 




A Mixed-Methods Longitudinal Assessment of Imposter Phenomenon in Third-Year Medical Students

Background:
Wayne State University School of Medicine administers an annual Independent Student Analysis (ISA) survey to gauge student feedback on a continuous spectrum. One topic of dissatisfaction in previous ISA surveys was financial aid and debt management counseling. WSUSOM currently has two financial aid officers in place for the M1-M4 class, approximately 1,200 students. The financial aid office provides information from their website rather than a one-on-one customized approach. Updates regarding deadlines to fill for FAFSA, scholarships, and resources for debt management are sent to students via newsletters quarterly. 

This study aims to gather and analyze student data using the ISA survey to develop long-term solutions to improve the student body’s experience with debt management and financial aid.

Methods:
Since there was proven dissatisfaction with financial aid on the previous ISA, the committee decided to remeasure this item. A Likert scale was used, and students were given the range option between “very satisfied” and “very dissatisfied. Students were also given a free response portion to offer narrative feedback. The survey was then analyzed, and free-response answers were appropriately coded. Following the survey analysis, the committee brainstormed and presented solutions to the administration. They then worked together to implement the suggested solutions. 

Results:
A total of 963 students from all four classes (M1-M4), responded to the survey question about the adequacy of debt management offered to students, which was a 99.6% response rate. The results showed that 20.5% of these students were either “dissatisfied” or “very dissatisfied.” In comparison, 41.7% were “satisfied” or “very satisfied” with students’ debt management counseling services. 

Comparably, 962 total students from all classes responded to the survey question about the quality of finance, with 23.8% combined “dissatisfied “or “very dissatisfied” and 56.8% students either “satisfied” or very satisfied” about the quality of financial aid administrative services being provided.

Conclusion 
Improved financial education resources are needed to prepare students for life after medical school. Debt management counseling should be integral to M1 orientation and frequently offered at information sessions and one-on-one counseling appointments. To improve students’ satisfaction, the ISA committee suggested continued efforts to improve services provided by the financial aid administration. This includes increasing personnel to attend to students’ needs, increasing the frequency of the financial aid newsletter distribution, publicizing pertinent information about financial resources, and increasing appointment times for students needing immediate assistance. Additionally, having a more transparent scholarship application process was suggested.


Student Perceptions on Debt Management and Financial Aid Counseling: Solutions for Administration

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**Abstract:**



Spectrum: An Early Exposure Program

Attitudes toward Remote Medical Education at an Urban Allopathic Medical School During the COVID-19 Pandemic

Introduction: The AAMC Core Competencies require graduating medical students to be able to counsel patients on sensitive conversations, yet many graduates feel unprepared to apply these skills in a clinical setting. The University of Connecticut has introduced virtual patient encounters into our preclinical curriculum to augment medical students' ability to counsel on sensitive topics. Methods: We developed a didactic module including pre-class reading, a virtual encounter on firearm ownership, and a team-based learning session for first-year medical students. Students completed live standardized patient (SP) encounters before and after completing the module. SP encounters were assessed using the Master Interview Rating Scale (MIRS). To assess the impact of the virtual patient encounter, MIRS scores before and after the didactic module were compared between the intervention group and control group, who did not complete the virtual module. Results: Compared to the control group, students completing the virtual encounter demonstrated a statistically significant improvement in MIRS scoring associated with the following criteria: types of questions asked (p<0.001), verbal facilitation (p=0.003), empathy (p<0.001), motivation for change (p=0.001), and shared decision making (p=0.002) during SP encounters. Both groups showed similar scores on these MIRS criteria before the virtual curriculum was implemented; the control group did not demonstrate a significant improvement on their second attempt. Discussion: Our findings suggest virtual patient encounters are an effective method for teaching medical students to counsel on sensitive topics. Medical schools should consider incorporating virtual patients into preclinical curricula to model challenging conversations in a cost-effective and standardized manner.

Closing the Gap in Medical Student Counseling: A Virtual Curriculum

Background: 
25-hydroxyvitamin D (vitamin D) inadequacy has been shown to be associated with an increased risk of progressing from prediabetes to diabetes. Although clinical trials have demonstrated vitamin D supplementation can lower the risk of developing diabetes for prediabetic patients, the actual factors associated with vitamin D supplementation usage for prediabetic individuals have yet to be fully elucidated. The goal of this study is to investigate demographic and socioeconomic factors associated with vitamin D supplement usage among prediabetic individuals in the United States to better understand the barriers this population faces in supplement access and utilization.

Methods:
In this cross-sectional study, the National Health and Nutrition Examination Survey results between 2011 and 2018 were analyzed. 3,424 prediabetic adults over the age of 20 without liver or kidney disease were isolated. The outcome of vitamin D supplement intake level was classified as “Low” (<400 International Units [IU]), “Medium” (400-800 IU), or “High” (>800 IU). An ordinal logistic regression was performed with the predictor variables of age, gender, race, education, insurance, and family income to poverty ratio while controlling for serum vitamin D concentration, vitamin D dietary intake, and body mass index. 

Results:
Significant predictors of higher levels of vitamin D supplementation included being female (Odds Ratio [OR]: 1.735, 95% Confidence Interval [CI]: 1.409 – 2.135), and income (OR: 1.148, 95% CI: 1.049 – 1.257). Furthermore, increases in education level were correlated with greater odds of higher vitamin D supplementation levels: High school (HS) graduates OR: 1.696, 95% CI: 1.109 – 2.594), Individuals with at least some college experience (OR: 1.752, 95% CI: 1.124 – 2.730), and College graduates (OR: 1.778, 95% CI: 1.129 – 2.800).

Conclusion:
Although the cross-sectional nature of the analysis precludes drawing causative conclusions, these findings suggest that being female, greater family income, and increased education level may be associated with higher levels of vitamin D supplementation in the prediabetic population in the United States. Further investigations may uncover reasons behind these relationships and the differential utilization of vitamin D supplementation. Understanding the drivers and barriers for vitamin D supplementation among prediabetic patients can guide public health efforts in protecting against the progression from prediabetes to diabetes.

Factors Associated With Vitamin D Supplementation in the Prediabetic Population

Background: Over the past few decades, pharmaceutical drug prices have fluctuated for a variety of reasons, such as inflation, manufacturer changes, and legislative policies. The purpose of this study is to track price changes for a specific set of drugs commonly prescribed to a large portion of the adult patient population in order to analyze historical factors contributing to pricing trends, as well as to serve as an informative tool for future and current pharmaceutical consumers. 

Methods: The IBM Micromedex® Redbook was queried to obtain the manufacturers and prices of five generic drugs (warfarin, atorvastatin calcium, amlodipine besylate, alprazolam, levothyroxine sodium) and four of their respective trade name drugs, excluding warfarin (Lipitor, Norvasc, Xanax, Synthroid). The Average Wholesale Price (AWP) and corresponding dates of these drugs’ production and sales were graphed on a scatter plot, with a trendline included to visualize the behavior of price changes over time.

Results: The AWP unit price of warfarin increased 236% from 1988 to 2020. The AWP unit price of Lipitor™ increased 659% from 1998 to 2021, while its generic counterpart atorvastatin calcium increased 5% from 2011 to 2022. The AWP unit price of Norvasc™ increased 644% from 1992 to 2022, while its generic counterpart amlodipine besylate decreased 0.03% from 2007 to 2020. The AWP unit price of Xanax™ increased 1811% from 1988 to 2022 while its generic counterpart alprazolam increased 3069% from 1993 to 2018. The AWP unit price of Synthroid™ increased 1654% from 1988 to 2022 while its generic counterpart levothyroxine sodium increased 1046% from 1991 to 2020. 

Conclusion: The rate of increase in these drugs’ AWP unit prices, notably for the trade name counterparts, exceeds that of the corresponding inflation rate in the United States for their specific manufacturing and sale time periods. The larger than expected increase in price could be attributed to legislative policy changes rather than microeconomic changes and inflation. However, this study is limited in the choice of drugs studied and database utilized, as the IBM Micromedex® Redbook only provides information on products approved by the U.S. Food and Drug Administration. Future studies could expand the studied drug selection or compare rate of increase in the U.S. to that of other countries. Overall, AWP unit prices for trade name drugs commonly prescribed to adult populations are increasing at a rate greater than natural inflation. 


Historical Analysis of Generic and Trade-Name Pharmaceutical Drug Prices

Background: Effective and efficient communication between physicians and patients is a major component of healthcare. As the U.S. population continues to grow, the Limited English Proficiency (LEP) population also continues to grow. Language barriers play a role in health disparities among LEP populations. LEP patients tend to report decreased patient satisfaction, they are less likely to obtain the recommended preventive care services and/or testing such as mammograms, pap smears, colon cancer screenings, and influenza vaccinations. Although LEP patients are less likely to have regular preventive screenings, they are more likely to have unnecessary testing when at the emergency department, more likely to be hospitalized, and have longer hospital stays when compared to English-speaking patients. They have a decreased understanding of diagnosis and treatment options, poorer adherence to treatment and follow-up for chronic illnesses, and increased medication complications. Therefore, LEP populations are at higher risk of poorer health outcomes. Furthermore, due to a language barrier, physicians may misunderstand a LEP patient’s symptoms, which may lead to diagnostic tests that are unnecessary. The purpose of this review was to explore interventions aimed at improving healthcare access and preventive screening services among LEP populations in the U.S.

Methods: A systematic literature search was performed from 1995 to 2020 using online medical, public health, and social science databases. These databases included: PubMed, JSTOR, Access Medicine, Google Scholar, OVID (MEDLINE), and Clinical Key. Older literature was used to understand if there have been any changes in language accessible services throughout the last 25 years. A total of 24 articles were utilized for this review.

Results: An analysis of the literature revealed past interventions focused on increasing healthcare education among LEP patients, increasing patient-physician communication by using bilingual physicians, increasing access to language services with mobile translation applications, and adapting evidence-based interventions as well as the P3 (Practice-, Provider-, and Patient level) Model.

Conclusion: Effective interventions working to increase language accessible services and build rapport with LEP patients by using bilingual physicians and mobile translating applications have been shown to increase healthcare access among LEP populations. It is essential that physicians take these findings into consideration to avoid adverse outcomes. Current research has not considered the impact of communication barriers on cancer diagnosis and treatment among LEP populations. Future efforts should focus on understanding how language barriers impact health outcomes among LEP cancer patients.

A Review of Interventions Addressing Ways to Improve Healthcare Access and Preventative Screening Services among Limited English Proficiency Population in the United States

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