PROBLEM: As of 2024, the nation's homeless population has been steadily growing. However, there is no standardized education in caring for unsheltered populations in higher medical education. Experiential programs have t...PROBLEM: As of 2024, the nation's homeless population has been steadily growing. However, there is no standardized education in caring for unsheltered populations in higher medical education. Experiential programs have the potential to increase students' knowledge of and confidence in caring for these individuals, but there is a lack of published research on longitudinal programs related to caring for this population. We designed, implemented, and evaluated a longitudinal 12-month educational innovation-Trojan Trainer-from 2021 to 2023 at the Keck School of Medicine at the University of Southern California (USC) on health professions students during their pre-clinical training. APPROACH: Based in constructivist learning theory and intentional redundancy to elevate cognitive, affective, and psychomotor domains, the Trojan Trainer program was created at USC to provide longitudinal experiential learning alongside more static classroom didactics. Emphasizing an interdisciplinary approach, medical (MD) and physician assistant (PA) students were put into small groups to meet weekly with an unhoused or temporarily housed individual, offering non-medical, social support. Pre- and post-surveys assessing students' knowledge of and confidence in caring for unsheltered populations were administered to student participants in the Trojan Trainer program during the 2021-2023 school years. OUTCOMES: 108 PA and MD students participated in the program over three years. After the year-long experience, there was a statistically significant increase in the domains of knowledge of- and confidence in caring for people experiencing unsheltered homelessness across the combined MD and PA cohorts (P < .001). NEXT STEPS: Education in caring for underserved populations is lacking at the training level for health professionals, leading to discomfort and uncertainty around caring for these patients later in their careers. Service-learning opportunities that focus on caring for unsheltered populations should be implemented early in health professionals' training.
PURPOSE: Interest in research careers among medical graduates is decreasing, and fewer physicians report research as their primary work activity. This study examines the implementation of a required scholarly research co...PURPOSE: Interest in research careers among medical graduates is decreasing, and fewer physicians report research as their primary work activity. This study examines the implementation of a required scholarly research course at the University of Maryland School of Medicine (UMSOM) and its impact on student research productivity. METHOD: This observational study analyzed data from the UMSOM graduating classes of 2013 through 2022 (n = 1,526). Data on scholarly productivity during medical school were collected from the Electronic Residency Application Service. Undergraduate grade point average (GPA), Medical College Admission Test (MCAT) percentile, and demographic data were collected from the American Medical College Application Service. Scholarly productivity was modeled as a function of undergraduate GPA, MCAT percentile, and FRCT implementation status. RESULTS: Implementation of the FRCT is associated with a significant increase in medical students' scholarly productivity during medical school. During the study, the per student mean increased from 0.75 to 2.22 for number of presentations, 0.56 to 1.65 for number of publications, and 0.17 to 0.59 for number of first-author publications. Likewise, the percentage of graduates with at least one publication increased from 29.4% to 68.8%, and the percentage of graduates with at least one first-author publication increased from 11.6% to 35.5%. Additional results show no significant change in the research productivity of MD-PhD students (who are exempt from the FRCT requirement) and no evidence of change in students' research experience before matriculation at UMSOM. CONCLUSIONS: These findings suggest that the implementation of a scholarly research requirement in the preclerkship phase of medical education at UMSOM contributes to increased student scholarly productivity.
PURPOSE: The United States Medical Licensing Examination (USMLE) Step 1 is the first of three board examinations that medical trainees must pass for licensure. The impact of delaying Step 1 on subsequent academic perform...PURPOSE: The United States Medical Licensing Examination (USMLE) Step 1 is the first of three board examinations that medical trainees must pass for licensure. The impact of delaying Step 1 on subsequent academic performance is of growing concern. To evaluate the effects of delaying the USMLE Step 1 exam on performance in Step 1, Step 2 clinical knowledge (CK), and clinical clerkships among students at one US medical school. METHOD: The researchers conducted a retrospective analysis of medical students matriculating in 2016, 2017, and 2019 at the University of Connecticut (UConn) School of Medicine. Students who delayed taking the Step 1 exam were compared with those who did not delay. Data on Step 1 scores, Step 2 CK scores, and clerkship performance (exams and final grades) were analyzed using two-sample t-tests, rank-sum tests, and chi-square test, based on the properties of the data. RESULTS: Of the 294 students analyzed, 80 (27%) delayed taking the Step 1 exam. Delayers had significantly lower Step 1 scores (mean [SD], 222.83 [16.76]) versus non-delayers (234.72 [15.56]; P < .001). Delayers also performed worse on home-grown clerkship exams and NBME shelf exams and had lower rates of honors in key clerkships. Furthermore, delayers had lower Step 2 CK scores (median [IQR]: 244 [236-251]) versus non-delayers (254 [245-261]; P < .001). CONCLUSIONS: Delaying USMLE Step 1 is associated with poorer performance in subsequent assessments, including clerkship exams and Step 2 CK scores. These findings suggest that delay may serve as a midstream indicator associated with broader academic challenges. Early identification of students at risk of delay and the provision of targeted academic support may improve educational outcomes and ensure timely progression through medical training.
PURPOSE: Characterization and measurement of reflective capacity (RC) - the ability to learn from experience to inform future learning and practice-in hospital trainees are critical to the design of medical education pro...PURPOSE: Characterization and measurement of reflective capacity (RC) - the ability to learn from experience to inform future learning and practice-in hospital trainees are critical to the design of medical education programs; testing interventions requires effective assessment. This study assessed RC among anesthesia trainees using the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT), which evaluates reflective writing. The study explored variation by training level, age, program, gender, and examined reliability and validity against an independent reflection measure. METHOD: A prospective observational study (February-May 2021) included anesthesia trainees across four training levels, four programs, and varied prior RC experience and intended sub-specialties. Participants completed the REFLECT instrument (using simulated and personal events) and the Residency Level Cognitive Behavior Survey (rCBS). Potential influencing factors (scenario realism, perceived importance, prior reflective writing) were examined. Data were analyzed for internal consistency (t-tests, ANOVA, Pearson's r) and interrater reliability (Cronbach's α, intraclass correlation coefficient). RESULTS: Participants (n = 172) demonstrated moderate RC (mean = 2.5/4, SD = 0.45), with no significant differences by training level, program, gender, or age. Greater perceived realism and prior reflective writing were independently associated with higher RC. Those with prior RC training rated reflection as more important and useful. Personal and simulated event scores were similar. REFLECT showed excellent interrater reliability (Cronbach's α = 0.95) and moderate correlation with the rCBS Reflection domain (r = 0.31, P = .001). CONCLUSIONS: REFLECT demonstrates robust psychometric properties for assessing RC in anesthesia trainees. Moderate RC scores support the need for interventions to enhance reflection. Although limited to one specialty and not assessing application to practice, the instrument's general structure suggests potential utility across postgraduate medical training contexts.
PROBLEM: Medical student research engagement is increasingly important in residency selection and professional development, yet structured, longitudinal mentorship programs remain limited, particularly in underserved set...PROBLEM: Medical student research engagement is increasingly important in residency selection and professional development, yet structured, longitudinal mentorship programs remain limited, particularly in underserved settings. Inconsistent access to mentors and growing reliance on artificial intelligence tools further threaten the development of rigorous research skills. Scalable solutions are needed to provide equitable, high-quality research training. APPROACH: A structured clinical research enterprise was developed under faculty mentorship and formally launched in 2019 at an academic medical center. The program recruits first-year medical students annually and engages them in a four-year longitudinal model emphasizing progressive leadership, interdisciplinary collaboration, and continuous mentorship. Students complete standardized onboarding, participate in multidisciplinary projects, attend biweekly team meetings, and use centralized digital infrastructure to manage projects. Defined roles for students, a research assistant, and the principal investigator evolve across training levels. Institutional funding supports administrative staff, biostatistical resources, and conference participation. OUTCOMES: Between 2019 and 2025, the group produced 28 peer-reviewed publications (4.6 per year) with a mean of 5.0 citations per article, achieved within a seven-year citation window. This compares favorably to a benchmark bibliometric analysis of medical student publications from 1980-2010 reporting 4.5 citations per article. Seventeen percent of publications were cited in clinical documents, and 68% appeared in high-impact journals (impact factor >5). Qualitative outcomes included improved professional identity formation, confidence in clinical environments, and preparedness for residency. Program enrollment expanded to over 50 active student researchers across three medical schools. NEXT STEPS: The model is being piloted for institutional expansion by recruiting additional faculty mentors. Formal program evaluation will assess long-term career outcomes, research involvement, and residency match success. The enterprise aims to serve as a scalable framework to improve equity, access, and excellence in medical student research training.
With the increasing popularity of hybrid medical education, this AM Last Page highlights practical tips for setting up and managing a hybrid classroom. The authors explain the advantages of both virtual and in-person cla...With the increasing popularity of hybrid medical education, this AM Last Page highlights practical tips for setting up and managing a hybrid classroom. The authors explain the advantages of both virtual and in-person classes as well as address the unique challenges of running a hybrid classroom.
PURPOSE: Delaying the United States Medical Licensing Examination (USMLE) Step 1 exam is often linked to poorer performance on Step 1, clerkship, and Step 2 Clinical Knowledge exams. This study developed and evaluated ex...PURPOSE: Delaying the United States Medical Licensing Examination (USMLE) Step 1 exam is often linked to poorer performance on Step 1, clerkship, and Step 2 Clinical Knowledge exams. This study developed and evaluated explainable machine learning (XML) models to predict Step 1 exam delay using student performance data and identify key predictors contributing to delay risk. METHOD: Data from 610 medical students at University of Connecticut School of Medicine for matriculation years 2016, 2017, 2019, 2020, 2021, and 2022 were analyzed, with 167 students (27.4%) delaying their Step 1 exam. XML models, including RF (random forest), XGBoost (Extreme Gradient Boosting), CatBoost (Categorical Boosting), and regularized logistic regression, were evaluated using 5-fold cross-validation and testing datasets. Misclassification rate (MCR), area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve (AUPRC) were used to compare model performance. Shapley Additive Explanations (SHAP) and permutation feature importance were applied to interpret key predictors. RESULTS: XGBoost outperformed all other models, achieving a median (IQR) MCR of 0.14 (0.11-0.17), AUROC of 0.80 (0.76-0.84), and AUPRC of 0.72 (0.60-0.78). SHAP and permutation feature importance analyses revealed that incorrect responses on the first Comprehensive Basic Science Self-Assessment (CBSSA), along with preclerkship foundational basic science and laboratory course scores, were the most influential predictors of Step 1 exam delay. Students with delays had a median (IQR) of 99 (82-112) incorrect responses on the first CBSSA vs 75 (56-92) for nondelayers (P < .001). Students with delays had significantly lower scores across the 5 preclerkship course blocks. CONCLUSIONS: Ensemble machine learning models, particularly XGBoost, provide strong predictive performance for identifying students at risk for delaying the Step 1 exam. Early academic indicators, such as CBSSA and course performance, can inform timely interventions, supporting students' academic progression and success.
PURPOSE: Crisis periods-defined as sustained disruptions to the clinical environment resulting in increased workload, exposure to high-acuity patient care, or limited access to coping resources-can lead to posttraumatic...PURPOSE: Crisis periods-defined as sustained disruptions to the clinical environment resulting in increased workload, exposure to high-acuity patient care, or limited access to coping resources-can lead to posttraumatic stress disorder (PTSD) among residents and fellows (trainees). By examining self-reported pandemic-related PTSD symptoms, associated risk factors, and their consequences, this study aims to identify vulnerable groups and inform institutional strategies to support trainee well-being during and after crisis events. METHOD: A multi-institutional cross-sectional survey was conducted at three U.S. academic medical centers between April-May 2022. Measures included the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5, range 0 to 5, scores ≥4 indicate probable PTSD), 4-item PROMIS Social Isolation scale (normed T-score range 0-100 scale with higher scores indicating greater isolation), items exploring intent to stay at one's institution, and demographics. Multivariable analysis adjusted for demographics, specialty, and post-graduate year. RESULTS: Of 6057 eligible trainees, 3185 (53%) participated in the survey, with 3109 completing the PTSD screening. A total of 190 (6%) trainees screened positive for self-reported PTSD symptoms. Multivariable analysis revealed that female trainees had a higher odds of screening positive for self-reported PTSD symptoms compared to males (OR 1.45, 95% CI 1.03-2.04, P=.03). Greater social isolation was independently associated with increased PTSD risk (OR 1.09, 95% CI 1.07-1.11, P<.001). Additionally, trainees who did not intend to remain at their institution after training were more likely to screen positive for PTSD (OR 1.74, 95% CI 1.17-2.58, P=.01). CONCLUSIONS: Female gender, greater social isolation, and reduced intention to remain at one's institution are independently associated with self-reported PTSD symptoms in trainees. Recognizing these relationships may enable healthcare leaders to proactively identify trainees at higher risk during crisis periods and to implement targeted, evidence-based interventions that promote well-being and workforce retention.
PROBLEM: Cardiovascular disease in Haiti is a major public health issue, yet fewer than 17 cardiologists are present nationwide. Consequently, general practitioners assume a substantial portion of demand for complex dise...PROBLEM: Cardiovascular disease in Haiti is a major public health issue, yet fewer than 17 cardiologists are present nationwide. Consequently, general practitioners assume a substantial portion of demand for complex disease management. Following their experience of the 2019 International Cardiology Curriculum Accessible by Remote Distance Learning (ICARDs), the authors identified a desire for practical instruction in echocardiography and a low-cost, effective imaging tool to screen for pertinent heart conditions. Current geopolitical challenges in Haiti render in-person echocardiography training unfeasible. A novel remote echocardiology curriculum for internal medicine residents could meet this challenge in a manner that is effective, sustainable, and sensitive to the Haitian context. APPROACH: University Hospital of La Paix served as the pilot intervention site for the Focused Echocardiography Training Intervention Package (FETIP). Portable ultrasound devices and a telemedicine-enabled robot were selected to mediate remote training, which was delivered in September of 2023 to 16 internal medicine residents over the course of 12 weeks. The first phase of training included live didactic sessions created and delivered by board-certified cardiologists. In the second phase, residents received hands-on training in image acquisition under direct supervision. The third phase centered on image interpretation skills. A diverse Training Advisory Board oversaw the implementation of FETIP and offered guidance for ongoing refinements. OUTCOMES: Results demonstrate improvement in three primary endpoints: fundamentals of knowledge, image acquisition, and image interpretation. Residents not only improved their technical performance but also applied echocardiography in appropriate clinical contexts, identifying previously unrecognized cases of heart failure. NEXT STEPS: The challenges in cardiovascular care in Haiti are ongoing, yet technology-driven training models like FETIP provide meaningful support to Haitian physicians, leading to future self-sufficiency in echocardiography. Further, the authors' experience offers the global medical community a scalable framework for echocardiography training for use in other resource-limited settings.
Westervelt M, Cavallaro S, Boedeker P
… +15 more, Robles J, Nguyen L, Stoddard H, Fishman M, Dorney K, Hirsch AW, Kung D, Lim J, Fisher K, Sarkar A, DiLeo M, Mogensen J, Ismail N, Maheshwari A, Miller KA
PURPOSE: Medical education relies on narrative feedback to improve and assess medical student performance in clinical settings, but ensuring sufficient quality narrative feedback remains challenging. This study examined...PURPOSE: Medical education relies on narrative feedback to improve and assess medical student performance in clinical settings, but ensuring sufficient quality narrative feedback remains challenging. This study examined the impact on quantity and quality of narrative feedback of a "two-step process" in which students first documented verbal feedback received from faculty, and then those same faculty reviewed and modified the feedback recorded by the student. METHOD: The two-step process was implemented at Baylor College of Medicine (BCM) in the context of planned direct observations of clerkship students and at Harvard Medical School (HMS) in the context of supervised clinical care by advanced elective students. Narrative feedback after the initiation of the two-step process (2023-2024) was compared to the baseline period (2022-2023). Differences in quantity of narrative feedback were measured by comparing word count and proportion of completed feedback forms (for supervised clinical care at HMS only). Quality of narrative feedback was measured by coding for and comparing markers of quality: behavior-based feedback, specific clinical examples, and absence of trait-based language. RESULTS: Using the two-step process was associated with increased narrative feedback at both institutions. Median word count per instance of feedback increased from 23 to 50 (P < .001) at BCM and from 75 to 119 (P < .01) at HMS. At HMS, the proportion of completed feedback forms also increased from 42 to 93% (P < .001). The proportion of narrative feedback instances with behavior-based feedback and specific examples significantly increased at both institutions, and use of trait-based language significantly decreased at HMS (P < .05 for all). CONCLUSIONS: A two-step process in which students and faculty co-create narrative feedback is feasible and enhances quantity and quality of feedback in various clinical settings. Future research should explore how student participation in generating narrative feedback impacts participating students and faculty.