The relationship between required physician letters of recommendation and decreasing diversity in osteopathic medical school admissions.

CONTEXT: Some racial and ethnic groups are underrepresented in the medical field because they face unique barriers to admission to medical school. One admission requirement that can present a barrier for applicants is the physician letter of recommendation (PLOR). Undergraduate students report confusion with the application process and lack of mentorship to be two of their biggest challenges to becoming a doctor. It is especially challenging to those who already have limited access to practicing physicians. Therefore, we hypothesized that in the presence of a PLOR requirement, the diversity of students who apply and matriculate into medical school will be decreased. OBJECTIVES: This study aims to determine if a relationship exists between a PLOR requirement for the medical school application and the proportion of underrepresented in medicine (URM) students applying and matriculating to that school. METHODS: A retrospective study was conducted utilizing data published by the American Association of Colleges of Osteopathic Medicine Application Services (AACOMAS) on the race and ethnicity of applicants and matriculants to osteopathic medical schools during the years 2009-2019. In total, 35 osteopathic schools with 44 campuses were included in the study. Schools were grouped based on whether they required a PLOR. For each group of schools, descriptive statistics were performed for the following variables: number of total applicants, class size, application rate per ethnicity, matriculation rate per ethnicity, number of applicants per ethnicity, number of matriculants per ethnicity, and percentage of student body per ethnicity. The Wilcoxon rank-sum test was utilized to detect differences between the two groups. Statistical significance was assessed at the α=0.05 level. RESULTS: Schools that required a PLOR showed decreases in the number of applicants across all races and ethnicities. Black students showed the greatest difference between groups and were the only ethnicity to show significant reductions across all outcomes in the presence of a PLOR requirement. On average, schools that required a PLOR have 37.3% (185 vs. 295; p<0.0001) fewer Black applicants and 51.2% (4 vs. 8.2; p<0.0001) fewer Black matriculants. CONCLUSIONS: This study strongly suggests a relationship between requiring a PLOR's and decreasing racial and ethnic diversity in medical school matriculants, specifically the Black applicants. Based on this result, it is recommended that the requirement of a PLOR be discontinued for osteopathic medical schools.

Assessment of Glycemic Control at St. Luke's Free Medical Clinic: Retrospective Chart Review.

BACKGROUND: A free clinic is a health care delivery model that provides primary care and pharmaceutical services exclusively to uninsured patients. With a multidisciplinary volunteer clinical staff, which includes physicians, social workers, dieticians, and osteopathic medical students, St. Luke's Free Medical Clinic (SLFMC) cares for over 1700 patients annually in Spartanburg, South Carolina. OBJECTIVE: This study aims to measure the change, over time, in patient hemoglobin A1c measurements at the SLFMC to quantify the success of the clinic's diabetes treatment program. METHODS: A prospective-retrospective chart review of patients (n=140) enrolled at the SLFMC between January 1, 2018, and January 1, 2021, was performed. Patients were stratified as having controlled (hemoglobin A1c<7.0, n=53) or uncontrolled (hemoglobin A1c≥7.0, n=87) diabetes relative to a therapeutic hemoglobin A1c target of 7.0, which is recommended by the American Diabetes Association. For both controlled and uncontrolled groups, baseline hemoglobin A1c values were compared to subsequent readings using a Wilcoxon matched-pairs signed rank test. Results from the SLFMC population were compared to the published literature on hemoglobin A1c from other free clinics. RESULTS: Patients with uncontrolled diabetes experienced significant reductions in median hemoglobin A1c at both 6 months (P=.006) and 1 year (P=.002) from baseline. Patients with controlled diabetes showed no significant changes. Black and Hispanic patients with uncontrolled diabetes experienced a 1.0% mean improvement in hemoglobin A1c over the study window. The SLFMC's wholly uninsured patient population showed a population rate of controlled diabetes (42%), which was similar to recent nationwide averages for adults with diabetes (51% to 56%), as reported by the National Health and Nutrition Examination Survey. The clinic's Hispanic population (n=47) showed the greatest average improvement in hemoglobin A1c of any ethnic group from baseline. Additionally, 61% of the SLFMC's Black population (n=33) achieved a hemoglobin A1c of <7.0 by the end of the study window, which surpassed the nationwide averages for glycemic control. CONCLUSIONS: We present free clinic hemoglobin A1c outcomes obtained through a retrospective chart review. Uninsured patients treated for diabetes at the SLFMC show a reduction in hemoglobin A1c, which is comparable to nationwide standards, although average hemoglobin A1c levels in this study were higher than nationwide averages. Black and Hispanic patients with uncontrolled diabetes showed a mean 1% improvement in hemoglobin A1c levels. These results represent some of the first in the literature emerging from a free clinic that is not affiliated with a major medical school.

Outcomes and charges associated with outpatient inguinal hernia repair according to method of anesthesia and surgical approach.

BACKGROUND: We conducted this study to compare short-term outcomes and charges between methods of hernia repair and anesthesia in the outpatient setting. METHODS: Using New York's state ambulatory surgery databases, we identified discharges for patients who underwent inguinal hernia repair. Patients were grouped by method of hernia repair. We compared hospital-based acute care encounters and total charges across groups. RESULTS: Locoregional anesthesia (5.2%) experienced a similar frequency of hospital-based acute care encounters within 30 days of discharge when compared with patients receiving general (6.0%) or having a laparoscopic procedure (6.0%). Risk-adjusted charges increased across groups (locoregional = $6,845 vs general = $7,839 vs laparoscopic = $11,340, P < .01). CONCLUSION: Open inguinal hernia repair under local anesthesia reduces healthcare charges.

Biotic control of stream fluxes: spawning salmon drive nutrient and matter export.

Organisms can control movements of nutrients and matter by physically modifying habitat. We examined how an ecosystem engineer, sockeye salmon (Oncorhynchus nerka), influences seasonal fluxes of sediments, nitrogen (N), and phosphorus (P) in streams of southwestern Alaska. The purpose of this study was to investigate whether salmon act as net importers or net exporters of matter and nutrients from streams and how these roles change as a function of salmon population density. We measured discharge and concentrations of suspended sediments and total N and P every 7-14 days for up to four summers in 10 streams spanning a gradient in salmon densities. We statistically allocated whole-season fluxes to salmon activities, such as excretion and bioturbation, and to export by hydrologic discharge. In addition, we used counts of spawning salmon to estimate nutrient and matter imports by salmon to streams. Large seasonal pulses of suspended sediments, P, and N were associated with salmon spawning activities, often increasing export an order of magnitude higher than during pre-salmon levels. Years and streams with more salmon had significantly higher levels of export of sediments and nutrients. In addition, years with higher precipitation had higher background export of P and N. Salmon exported an average of the equivalent of 189%, 60%, and 55% of total matter, P, and N that salmon imported in their bodies. The relative magnitude of export varied; salmon exported more than their bodies imported in 80%, 20%, and 16% across all streams and years for sediments, P, and N, respectively. A bioassay experiment indicated that the P exported by salmon is directly available for use by primary producers in the downstream lake. These results demonstrate that salmon not only move nutrients upstream on large spatial scales via their migration from the ocean and subsequent death, but also redistribute matter and nutrients on finer spatial scales through their spawning activities.