Mental Health from Medical School to Medical Practice: Finding a Path Forward.

Medical students, residents, and practicing physicians experience high burnout, depression, and suicide rates, and the COVID-19 pandemic has exacerbated stress for many.1-6 While laudable, current well-being efforts appear insufficient to meet the challenges that so many are facing. This essay explores approaches that individuals and organizations can take to promote mental health and well-being from medical school to practice.

The impact of death and dying on the personhood of medical students: a systematic scoping review.

BACKGROUND: The re-introduction of medical students into healthcare systems struggling with the COVID-19 pandemic raises concerns as to whether they will be supported when confronted with death and dying patients in resource-limited settings and with reduced support from senior clinicians. Better understanding of how medical students respond to death and dying will inform educationalists and clinicians on how to best support them. METHODS: We adopt Krishna's Systematic Evidence Based Approach to carry out a Systematic Scoping Review (SSR in SEBA) on the impact of death and dying on medical students. This structured search process and concurrent use of thematic and directed content analysis of data from six databases (Split Approach) enhances the transparency and reproducibility of this review. RESULTS: Seven thousand six hundred nineteen were identified, 149 articles reviewed and 52 articles included. The Split Approach revealed similar themes and categories that correspond to the Innate, Individual, Relational and Societal domains in the Ring Theory of Personhood. CONCLUSION: Facing death and dying amongst their patients affect how medical students envisage their personhood. This underlines the need for timely, holistic and longitudinal support systems to ensure that problems faced are addressed early. To do so, there must be effective training and a structured support mechanism.

Building Equity, Inclusion, and Diversity Into the Fabric of a New Medical School: Early Experiences of the Kaiser Permanente Bernard J. Tyson School of Medicine.

In July 2020, the Kaiser Permanente Bernard J. Tyson School of Medicine opened in Pasadena, California, with an inaugural class of 50 students. The school endeavors to address systemic barriers that have contributed to health care and educational disparities in the United States. To realize its vision for change, equity, inclusion, and diversity (EID) have been woven throughout the school. Board members were chosen in part based on their commitment to the core values of EID. The board developed mission, vision, and values statements that explicitly avow a commitment to EID and recruited a dean (and the dean recruited leaders) who espoused and evinced these values. Leaders, faculty, and staff received training to foster an inclusive environment and ensure accountability. The school developed a curriculum that has been thoroughly evaluated for its representative and inclusive content by a team drawn from all departments. The diverse first class, selected through a holistic admissions approach, has access to student support systems that emphasize an appreciation of the distinct experiences and context of each student. The school plans a rigorous evaluation program to assess its performance in EID. Although the school may well fall short of achieving all of its EID objectives, by learning from its experiences and from evidence of others in academic medicine, the school recognizes its opportunity to continue to come closer to achieving its goals and to help shape and contribute to the national and international discourse on EID.

Transition to multiple mini interview (MMI) interviewing for medical school admissions.

INTRODUCTION: The multiple mini interview (MMI) has been incorporated into the holistic review process in the selection of students to US medical schools. The MMI has been used to evaluate interpersonal and intrapersonal attributes which are deemed as necessary for future physicians. We hypothesized that there would be little difference in overall MMI evaluation data compared with traditional interview ratings. METHODS: The University of North Carolina School of Medicine developed an interview process that included a traditional interview and MMI format during the 2019 admissions cycle. Evaluation data along with key demographic variables for 608 MD program applicants were analyzed using descriptive and inferential statistical analyses. RESULTS: The MMI format slightly favored female over male applicants (p = 0.002) but did not select for or against applicants based on age, race/ethnicity, underserved/rural area upbringing, or indicators of disadvantage. Out of 608 applicants, 356 (59%) completed a post-interview survey in which the experience was positively rated. DISCUSSION: Based on our experience, the use of a hybrid model of traditional interviews complemented with MMI stations provided greater details in the assessment of medical school applicants while obtaining equivalent data and acceptability amongst applicants.

What motivates medical students to learn about traditional medicine? A qualitative study of cultural safety in Colombia.

OBJECTIVES: This study explored motivation dynamics of medical students engaging with traditional medicine in Colombia. METHODS: We conducted a qualitative descriptive study as part of a larger participatory research effort to develop a medical education curriculum on cultural safety. Four final-year medical students participated in a five-month program to strengthen knowledge of traditional medicinal plants with schoolchildren in Cota, a municipality outside Bogota with a high proportion of traditional medicine users. Students and schoolteachers co-designed the program aimed to promote the involvement of school children with traditional medicine in their community. The medical students shared written narratives describing what facilitated their work and discussed experiences in a group session. Inductive thematic analysis of the narratives and discussion derived categories of motivation to learn about traditional medicine. RESULTS: Five key learning dynamics emerged from the analysis: (1) learning from/with communities as opposed to training them; (2) ownership of medical education as a result of co-designing the exercise; (3) rigorous academic contents of the program; (4) lack of cultural safety training in university; and (5) previous contacts with traditional knowledge. CONCLUSIONS: We identified potential principles for engaged cultural safety training for medical students. We will use these in our larger training program. Our results may be relevant to other researchers and medical educators wanting to improve the interaction of medical health professionals in multicultural settings with people and communities who use traditional medicine. We expect these professionals will be better prepared to recognize and address intercultural challenges in their clinical practice.

Mindful medical practice: An innovative core course to prepare medical students for clerkship.

BACKGROUND: Medical students show a decline in empathy and ethical reasoning during medical school that is most marked during clerkship. We believe that part of the problem is that students do not have the skills and ways of being and relating necessary to deal effectively with the overwhelming clinical experience of clerkship. APPROACH: At McGill University in Montreal, starting in January 2015, we have taught a course on mindful medical practice that combines a clinical focus on the combination of mindfulness and congruent relating that is aimed at giving students the skills and ways of being to function effectively in clerkship. The course is taught to all medical students in groups of 20, weekly for 7 weeks, in the 6 months immediately prior to clerkship, a time when students are very open to learning the skills they need to take effective care of patients. EVALUATION: The course has been well accepted by students as evidenced by their engagement, their evaluations, and their comments in the essays that they write at the end of the course. In a follow-up session at the simulation centre one year later students remember clearly and enact what they were taught in the course. REFLECTION: The next steps will be to conduct a formal evaluation of the effect of our teaching that will involve a combination of qualitative methods to clarify the nature of the impact on our students and a quantitative assessment of the difference the course makes to students' experience and performance in clerkship.

Professionalism: The Wrong Tool to Solve the Right Problem?

Medical schools and other higher education institutions across the United States are grappling with how to respond to racism on and off campus. Institutions and their faculty, administrators, and staff have examined their policies and practices, missions, curricula, and the representation of racial and ethnic minority groups among faculty, staff, and students. In addition, student-led groups, such as White Coats for Black Lives, have emerged to critically evaluate medical school curricula and advocate for change. Another approach to addressing racism has been a focus on the role of professionalism, which has been variably defined as values, traits, behaviors, morality, humanism, a role, an identity, and even a social contract.In this article, the authors consider the potential role that professionalism might play in responding to racism in medical education and at medical schools. They identify 3 concerns central to this idea. The first concern is differing definitions of what the problem being addressed really is. Is it isolated racist acts or institutional racism that is a reflection of white supremacy? The second concern is the notion that professionalism may be used as a tool of social control to maintain the interests of the social groups that dominate medicine. The third concern is that an overly simplistic application of professionalism, regardless of how the problem of racism is defined, may result in trainees practicing professionalism that is performative rather than internally motivated. The authors conclude that professionalism may complement a more systematic and holistic approach to addressing racism and white supremacy in medical education, but it is an insufficient stand-alone tool to address this core problem.

Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-Institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools.

PURPOSE: To examine differences in students' empathy in different years of medical school in a nationwide study of students of U.S. DO-granting medical schools. METHOD: Participants in this cross-sectional study included 10,751 students enrolled in 41 of 48 campuses of DO-granting medical schools in the United States (3,616 first-year, 2,764 second-year, 2,413 third-year, and 1,958 fourth-year students). They completed a web-based survey at the end of the 2017-2018 academic year that included the Jefferson Scale of Empathy and the Infrequency Scale of the Zuckerman-Kuhlman Personality Questionnaire for measuring "good impression" response bias. Comparisons were made on empathy scores among students in different years of medical school using analysis of covariance, controlling for the effect of "good impression" response bias. Also, comparisons were made with preexisting data from students of U.S. MD-granting medical schools. RESULTS: A statistically significant decline in empathy scores was observed when comparing students in the preclinical (years 1 and 2) and the clinical (years 3 and 4) phases of medical school (P < .001); however, the magnitude of the decline was negligible (effect size =0.13). Comparison of findings with MD students showed that while the pattern of empathy decline was similar, the magnitude of the decline was less pronounced in DO students. CONCLUSIONS: Differences in DO-granting and MD-granting medical education systems, such as emphasis on provision of holistic care, hands-on approaches to diagnosis and treatment, and patient-centered care, provide plausible explanations for disparity in the magnitude of empathy decline in DO compared with MD students. More research is needed to examine changes in empathy in longitudinal study and explore reasons for changes to avert erosion of empathy in medical school.

Mission Drift: Are Medical School Admissions Committees Missing the Mark on Diversity?

Diversity initiatives in U.S. medical education, following the passage of the Civil Rights Act of 1964, were geared toward increasing the representation of African Americans-blacks born in the United States whose ancestors suffered under slavery and Jim Crow laws. Over time, blacks and, subsequently, underrepresented minorities in medicine (URMs), became a proxy for African Americans, Puerto Ricans, Mexican Americans, and Native Americans, thus obscuring efforts to identify and recruit specifically African Americans. Moreover, demographic shifts resulting from the recent immigration of black people from Africa and the Caribbean have both expanded the definition of "African American medical students" and shifted the emphasis from those with a history of suffering under U.S. oppression and poverty to anyone who meets a black phenotype.Increasingly, research indicates that African American patients fare better when their physicians share similar historical and social experiences. While all people of color risk discrimination based on their skin color, not all have the lived experience of U.S.-based, systematic, multigenerational discrimination shared by African Americans. In the high-stakes effort to increase URM representation in medical school classes, admissions committees may fail to look beyond the surface of phenotype, thus missing the original intent of diversity initiatives while simultaneously conflating all people of color, disregarding their divergent historical and social experiences. In this Perspective, the authors contend that medical school admissions committees must show greater discernment in their holistic reviews of black applicants if historical wrongs and continued underrepresentation of African Americans in medicine are to be redressed.

An Investigation of the Relationship Between COMLEX-USA Licensure Examination Performance and State Licensing Board Disciplinary Actions.

PURPOSE: Passing the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) serves as a licensing requirement, yet there is limited understanding between this high-stakes exam and performance outcomes. This study examined the relationship between COMLEX-USA scores and disciplinary actions received by osteopathic physicians. METHOD: Data for osteopathic physicians (N = 26,383) who graduated from medical school between 2004 and 2013 were analyzed using multinomial logistic regression to assess the relationship between COMLEX-USA scores and placement into one of 3 disciplinary action categories relative to no action received, controlling for years in practice and gender. RESULTS: Less than 1% of physicians in this study (n = 187) had a disciplinary action(s). Controlling for all COMLEX-USA levels, years in practice, and gender, higher Level 3 scores were associated with significant decreased odds for all action categories: revoked licensed (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.36, 0.72; P < .001), imposed limitations to practice (OR = 0.59, 95% CI 0.41, 0.84; P < .01), and other action imposed (OR = 0.48, 95% CI 0.33, 0.69; P < .001), relative to not receiving an action. In these same models, higher Level 2 Performance Evaluation Biomedical/Biomechanical Domain scores decreased the odds for an action that revoked a license (OR = 0.75, 95% CI 0.58, 0.98; P < .05) and imposed limitations to practice (OR = 0.64, 95% CI 0.49, 0.84; P < .001). CONCLUSIONS: These findings provide evidence that the COMLEX-USA delivers useful information regarding the likelihood of a practitioner receiving state board disciplinary actions.

The Dean's Certificate of Distinction in Native Hawaiian Health.

Certificates of Distinction at USA medical schools are given to students who have shown additional commitment and effort in areas such as global health and social justice. In 2014, the Dean's Certificate of Distinction in Native Hawaiian Health (COD-NHH), at the John A. Burns School of Medicine (JABSOM), was designed to offer more experience and knowledge in Native Hawaiian health, as well as directly benefiting Native Hawaiian communities through personal and cultural growth, service learning and scholarly projects. The COD-NHH utilises the Department of Native Hawaiian Health 'na pou kihi' framework represented by a hale (house). This framework embodies the Native Hawaiian holistic view of health and incorporates traditional values and cultural strengths, critical to ensure that students can work comfortably and effectively in our communities. Activities focus on four 'pou kihi' (pillars): (1) cultural knowledge and space; (2) community/environmental stewardship; (3) knowledge advancement and dissemination; and (4) social justice. The first cohort received their COD-NHH in May 2017. Interest among JABSOM students is expanding. The COD-NHH, though well received, has required some modification including new technology for data collection of requirements. Feedback from the community is positive and continued community partnerships allow for opportunities of engagement with the student.

A model for sustainable laser tattoo removal services for adult probationers.

PURPOSE: The purpose of this paper is to describe a sustainable free laser tattoo removal clinic for economically disadvantaged adult probationers. DESIGN/METHODOLOGY/APPROACH: This paper describes the partnerships, methods and challenges/lessons learned from the implementation of a free monthly laser tattoo removal program for adult probationers within a medical school setting in California. FINDINGS: Possible patients are identified via a collaboration with the county's Probation Department. Founded in 2016, this monthly program has provided tattoo removal services to >37 adult patient probationers, many of whom receive follow-up treatments. Clients seek to remove about four blue/black ink tattoos. Since its inception, 23 dermatology residents have volunteered in the program. Challenges to patients' ongoing participation primarily pertain to scheduling issues; strategies for overcoming barriers to participation are provided. No safety concerns have emerged. SOCIAL IMPLICATIONS: Programs such as this public-private partnership may benefit probationers by eliminating financial barriers associated with tattoo removal. This model supports the training of cohorts of dermatologists seeking community service opportunities related to laser medicine. Others seeking to implement a similar program may also consider expanding treatment days/times to facilitate access for working probationers, providing enrollment options for other health and social services (e.g. public insurance, food stamp programs) and hosting a mobile onsite clinic to address clients' physical and mental health needs. ORIGINALITY/VALUE: This paper describes a unique collaboration between law enforcement and a medical school and it may assist other jurisdictions in establishing free tattoo removal programs for the benefit of probationers. The methods described overcome challenges regarding the implementation of this specialized clinical service.

Design, Implementation, and Evaluation of a Diversity Program for Radiology.

RATIONALE AND OBJECTIVES: Diagnostic radiology training programs are less diverse than graduating US medical school classes and the patient populations they serve. Inclusion of physicians who are underrepresented minorities in medicine (URMM) can strengthen the profession and help to meet the needs of an increasingly diverse population. Our Department of Radiology developed and implemented a plan to increase the number of URMMs in our residency applicant pool and residency training program. MATERIALS AND METHODS: We designed a recruitment strategy to diversify the radiology residency applicant pool. This included website development, advertising, early exposure opportunities, travel to predominantly minority institutions and national meetings, and mentoring URMM medical students. We implemented parallel activities to increase the number of URMMs in our residency program. These included holistic screening tools for residency application review, a diverse residency recruitment committee, a welcome environment for visiting candidates, and "Second Look Weekend" visits for talented candidates. Primary outcomes measured include change in percentages of URMM applicants in our applicant pool and URMM residents in our residency program. RESULTS: The percentage of URMM radiology residency applicants increased from 7.5% (42 of 556) of the total applicant pool in the 2012 to 2013 recruitment year to 12.6% (98 of 777) in the 2017 to 2018 recruitment year (P = .001). URMM radiology residency representation increased from 0% (0 of 32) in the 2013 to 2014 academic year to 20% (6 of 30) in the 2018 to 2019 academic year (P = .01). CONCLUSION: An intentional, strategic diversity program can diversify an institution's residency applicant pool and increase representation of URMMs in a diagnostic radiology residency program.

Use of student feedback to drive quality improvement (QI) in a preclinical U.S. medical school course.

Medical educators are continually looking for ways to enhance integrated learning and help students see how the material taught in their various courses is inter-related. . At Stony Brook School of Medicine, we embarked on a school-wide new curriculum called the Learning focused, Experiential, Adaptive, Rigorous and Novel (LEARN) curriculum and developed several integrated courses that were not based in specific departments. As part of this process, the pre-clinical (Phase-1) curriculum was shortened to 17 months to accommodate an expanded set of clinical offerings. The new structure called for teachers from different departments to lead and conduct the integrated blocks of pre-clinical courses. In this paper, we describe our discouraging experience with the first iteration of an integrated course in Cardiology, Pulmonology and Renal organ systems (CPR), and its transformation into a highly successful second iteration. This involved a systematic course quality improvement (QI) process within the context of a larger school wide curricular reform. As a result, student overall satisfaction with the course increased from 22% (28 of 127 responders) to 83% (111 of 134 responders); the mean score on a standardized NBME content exam increased by 6.7%. We report the systematic process we used to collect data from students and faculty that helped facilitate quality improvement in a key course in Phase-1 of our LEARN curriculum.

Addressing the Absence of Black Men in Medicine.

There is a profound absence of Black men in medicine. Addressing this issue requires a concerted and holistic effort that includes learning from the current generation of medical students. This article summarizes three medical student perspectives presented as posters at the National Academies of Science, Engineering, and Medicine inaugural workshop on the growing absence of Black men in medicine. These posters present perspectives from men of color each from one of the three historically Black medical colleges in the country. The authors provide narratives on the importance of early access to resources and adequate inter-generational mentorship in preparing Black men for a career in medicine. Popular culture is also discussed as a means of facilitating further engagement of premedical Black students. Black men interested in medicine face unique challenges in the United States, and initiatives to improve the declining matriculation rate into medical schools need to be well-designed, relevant, and facilitating of early mentorship.

Affirmative Action and Holistic Review in Medical School Admissions: Where We Have Been and Where We Are Going.

Current challenges to affirmative action policies are cause for concern for medical schools that employ holistic admissions processes, which consider an applicant's race, ethnicity, gender, status as a first-generation college student, educational and socioeconomic status, geographical location, past experiences with minority and underserved populations, social capital, and immigration status. Students from minority and underserved communities bring with them experiences and perspectives that may enhance the care they provide to underserved patients, improving patient outcomes. Student body diversity is also associated with increases in students' academic performance, retention, community engagement, cooperation, and openness to different ideas and perspectives, and institutions that foster diversity tend to be nurturing places where all students and faculty can thrive.The use of race as a factor in admissions has been upheld in three Supreme Court decisions. Yet, the Supreme Court likely will rule again on this issue. In the meantime, medical schools must maintain or increase support for science, technology, engineering, and math academic enrichment programs at all levels, stay informed about their institutional climate, and support a holistic admissions process that considers race and socioeconomic status. Doing so will help disadvantaged students overcome the intergenerational barriers created by race, ethnicity, and poverty and help grow a culturally competent health care workforce, which is essential to improving individual and population health and narrowing racial and ethnic health disparities.

An Education in Osteopathic Ultrasonography (AEIOU) Program: One Institution's Approach to Advancing an Ultrasonography Curriculum.

Advances in ultrasonography (US) have allowed this technology to play an increasingly important role in numerous fields of medicine. It is important that medical schools incorporate this broadly applicable tool into their curricula. Touro University College of Osteopathic Medicine-CA has implemented a progressive US curriculum that is intended to complement osteopathic education, keep pace with medical advances, and arm future physicians with the most advanced skills and tools to practice medicine. In this article, the authors highlight the importance of US training in medical education and demonstrate the relative ease, cost-effectiveness, and direct benefit to students of implementing such a curriculum. The authors discuss the specifics of the US curriculum in osteopathic undergraduate medical education and describe how a staged rollout helped the college address the need for funding, faculty, and facilities. Plans for continued expansion, the successful and effective use of peer educators, the outcomes measured from this project, and avenues for further study are also discussed.

A meta-analytic perspective on the valid use of subjective human judgement to make medical school admission decisions.

While medical educators appear to believe that admission to the medical school should be governed, at least in part, by human judgement, there has been no systematic presentation of evidence suggesting it improves selection. From a fair testing perspective, legal, ethical, and psychometric considerations, all dictate that the scientific evidence regarding human judgement in selection should be given consideration. To investigate the validity of using human judgements in admissions, multi-disciplinary meta-analytic research evidence from the wider literature is combined with studies from within medical education to provide evidence regarding the fairness and validity of using interviews and holistic review in medical school admissions. Fourteen studies, 6 of which are meta-analytic studies that summarized 292 individual studies, were included in the final review. Within these studies, a total of 33 studies evaluated the reliability of the traditional interview. These studies reveal that the interview has low to moderate reliability (~.42) which significantly limits its validity. This is confirmed by over 100 studies examining interview validity which collectively show interview scores to be moderately correlated with important outcome variables (corrected value ~.29). Meta-analyses of over 150 studies demonstrate that mechanical/formula-based selection decisions produce better results than decisions made with holistic/clinical methods (human judgement). Three conclusions regarding the use of interviews and holistic review are provided by these meta-analyses. First, it is clear that the traditional interview has low reliability and that this significantly limits its validity. Second, the reliable variance from interview scores appears moderately predictive of outcomes that are relevant to consider in medical school admission. And third, the use of holistic review as a method of incorporating human judgement is not a valid alternative to mechanical/statistical approaches as the evidence clearly indicates that mechanistic methods are more predictive, reliable, cost efficient, and transparent.