Relationships between preadmission variables and academic outcomes for postbaccalaureate students in medical school.

There is currently little guidance for medical school admissions committees regarding how to weigh postbaccalaureate program grades relative to undergraduate grades. This study was designed to address this issue. Admissions data, preclerkship course performance and United States Medical Licensing Exam (USMLE) Step 1 results were analyzed over three years for University of California, San Diego (UCSD) postbaccalaureate premedical (PBPM) students (n = 25), students who participated in other postbaccalaureate programs (n = 34), and for the remainder of the medical students who did not participate in any postbaccalaureate programs (n = 329). UCSD PBPM program alumni did not significantly differ in their cumulative academic performance on exams in preclerkship courses and USMLE Step 1 pass rates compared to the rest of the class despite their significantly lower GPA, lower Biology, Chemistry, Physics and Math (BCPM) GPA, and Medical College Admissions Test (MCAT) percentiles. For students who participated in the PBPM programs, PBPM program GPA was a significant predictor of preclerkship academic performance and USMLE Step 1 performance. When assessing academic readiness of applicants who have completed postbaccalaureate programs, admissions committees might closely consider the postbaccalaureate program GPA in addition to other academic metrices such as BCPM GPA and MCAT score.

Associations of Postbaccalaureate Coursework with Underrepresented Race/Ethnicity, Academic Performance, and Primary Care Training among Matriculants at Five California Medical Schools.

Studies employing data collected over 15 years ago suggested salutary effects of postbaccalaureate (PB) premedical coursework on medical school class diversity, academic performance, and primary care training. The studies may have limited current applicability given changes in medical school admissions paradigms and population demographics. Using data from interviewees at >1 of 5 California public medical schools between 2011-2013 (N=3805), we examined associations of PB premedical coursework with underrepresented race/ethnicity; academic performance (United States Medical Licensing Examination Step 1 and Step 2 scores, clerkship Honors); and primary care residency. Adjusting for age, sex, and year, PB coursework was associated with underrepresented race/ethnicity, but not after further adjustment for self-designated disadvantage (SDA). PB coursework was not associated with academic performance or primary care residency. Holistic consideration of SDA and UIM status in admissions coupled with robust matriculant support may merit exploration as an alternative to PB coursework for increasing medical school diversity.

The Relationships among Self-Designated Disadvantage, Socioeconomic Disadvantage, and Academic Performance in Medical School: A Multi-Institutional Study.

As medical schools seek to address the growing disparity between the socioeconomic makeup of their students and the general population, it is important to understand the academic trajectory of disadvantaged students. We used a locally-developed multicomponent socioeconomic disadvantage (SED) measure and the self-designated disadvantaged (SDA) question ["yes" (+) or "no" (-)] from the American Medical College Application Service application to examine academic performance of students from three disadvantaged categories (high SED/SDA+, high SED/SDA-, and low SED/SDA+); with low SED/SDA-as the reference group across five California schools. Compared with reference, the DA+ subgroups scored lower on USMLE Step 1 and Step 2 Clinical Knowledge examinations and received fewer clerkship Honors. After adjustment for academic metrics and sociodemographic variables, high SED subgroups performed similarly to reference, but performance gaps for low SED/SDA+ students persisted. Medical schools must better understand the institutional and other drivers of academic success in disadvantaged students.

Dean's Perspective on Academic Communities at UC San Diego, School of Medicine.

INTRODUCTION AND BACKGROUND: In 2010, the UC San Diego School of Medicine launched a new curriculum, the integrated scientific curriculum. As part of this curricular redesign, the school instituted academic communities. This perspective article outlines our experience with the first 8 years of these academic communities. SINGLE-INSTITUTION EXPERIENCE: We initiated academic communities with the hope that this structure would cultivate enhanced student-student and student-faculty engagement, improve faculty-student mentoring, and create additional service-learning and student leadership opportunities. The communities would also provide an environment for small group learning throughout the 4-year curriculum. After 8 years of experience, a comparison of student survey data pre- and post establishment of academic communities demonstrated enhanced connectedness between students and faculty and higher scores for faculty mentoring and for career planning. Our own lived experience with the communities revealed several unanticipated outcomes. The community directors became a source of support and advice for one another. Some faculty and administrators whose previous roles were affected by start of the academic communities needed to adjust expectations. CONCLUSIONS: The establishment of academic communities was associated with improvement in student-faculty engagement, student assessment of faculty mentoring, and career planning.

Do Admissions Multiple Mini-Interview and Traditional Interview Scores Predict Subsequent Academic Performance? A Study of Five California Medical Schools.

PURPOSE: To compare the predictive validities of medical school admissions multiple mini-interviews (MMIs) and traditional interviews (TIs). METHOD: This longitudinal observational study of 2011-2013 matriculants to five California public medical schools examined the associations of MMI scores (two schools) and TI scores (three schools) with subsequent academic performance. Regression models adjusted for sociodemographics and undergraduate academic metrics examined associations of standardized mean MMI and TI scores with United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge (CK) scores and, for required clerkships, with mean National Board of Medical Examiners Clinical Science subject (shelf) exam score and number of honors grades. RESULTS: Of the 1,460 medical students, 746 (51.1%) interviewed at more than one study school; 579 (39.7%) completed at least one MMI and at least one TI. Neither interview type was associated with Step 1 scores. Higher MMI scores were associated with more clerkship honors grades (adjusted incidence rate ratio [AIRR] 1.28 more [95% CI 1.18, 1.39; P < .01] per SD increase) and higher shelf exam and Step 2 CK scores (adjusted mean 0.73 points higher [95% CI 0.28, 1.18; P < .01] and 1.25 points higher [95% CI 0.09, 2.41; P = .035], respectively, per SD increase). Higher TI scores were associated only with more honors grades (AIRR 1.11 more [95% CI 1.01, 1.20; P = .03] per SD increase). CONCLUSIONS: MMI scores were more strongly associated with subsequent academic performance measures than were TI scores.

Do Multiple Mini-Interview and Traditional Interview Scores Differ in Their Associations With Acceptance Offers Within and Across Five California Medical Schools?

PURPOSE: In single-school studies, multiple mini-interview (MMI) and traditional interview (TI) scores are associated with acceptance offers. Unexamined is whether scores at one school are associated with acceptance at other schools; such analyses would mitigate single-school design biases and better estimate how well interviews capture desired applicant attributes. Using data from the 5 California Longitudinal Evaluation of Admissions Practices (CA-LEAP) medical schools, the authors examined associations of MMI and TI scores with acceptance offers within and across schools. METHOD: The analyses included applicants who interviewed at ≥1 CA-LEAP school during the 2011-2013 admissions cycles. Three CA-LEAP schools employed TIs and 2 employed MMIs. Interview scores were standardized (z scores: mean = 0, SD = 1), and associations with acceptance offers were examined within and across schools in analyses stratified by school, adjusting for applicant sociodemographics, academic metrics, year, and total number of interviews. RESULTS: Of 4,993 applicants interviewed, 428 (8.6%) interviewed at both MMI schools, 681 (13.6%) at ≥2 TI schools, and 1,327 (26.6%) at ≥1 MMI and ≥1 TI school. For each school, acceptance was associated with interview score at that school and also with interview scores at the other 4 schools. Cross-school associations of MMI versus TI scores with acceptance did not differ statistically. CONCLUSIONS: Interview score at a given school was associated with acceptance at the other 4 schools, with no significant differences in associations for MMIs versus TIs. The findings suggest both MMIs and TIs captured attributes valued by admissions teams across CA-LEAP schools.

A summer prematriculation program to help students succeed in medical school.

Medical schools with a diverse student body face the challenge of ensuring that all students succeed academically. Many medical schools have implemented prematriculation programs to prepare students from diverse backgrounds; however, evidence on their impact is largely lacking. In this study, we analyzed participants' demographics as well as the impact of the prematriculation program on Year 1 performance. Predictive validity of the program was assessed and compared to other traditional predictors, including grade point average (GPA) and Medical College Admission Test (MCAT) scores and subscores. Linear mixed effect models determined the impact of the prematriculation program, and linear regression analysis assessed the predictive value of the overall score in the prematriculation program and other traditional predictors. Demographics of students participating in the prematriculation program from 2013 to 2015 (n = 75) revealed a significantly higher prevalence of academically disadvantaged students including older students, students with lower GPA and MCAT scores and students of racial and ethnic populations that are underrepresented in medicine, compared to non-participants (n = 293). Participants performed significantly better in Year 1 courses that were covered in the prematriculation program compared to courses that were not covered. The overall performance in the prematriculation program correlated significantly with Year 1 performance and was found to be a strong predictor for Year 1 performance. This study suggests that a prematriculation program can help students to succeed in the first year of medical school. The results have implications for medical schools seeking to implement or evaluate the effectiveness of their prematriculation program.

Medical School Applicant Characteristics Associated With Performance in Multiple Mini-Interviews Versus Traditional Interviews: A Multi-Institutional Study.

PURPOSE: To examine applicant characteristics associated with multiple mini-interview (MMI) or traditional interview (TI) performance at five California medical schools. METHOD: Of the five California Longitudinal Evaluation of Admission Practices consortium schools, three used TIs and two used MMIs. Schools provided retrospective data on 2011-2013 admissions cycle interviewees: age, gender, race/ethnicity (underrepresented in medicine [UIM] or not), disadvantaged (DA) status, undergraduate GPA, Medical College Admission Test (MCAT) score, and interview score (standardized as z score; mean = 0; SD = 1). Adjusted linear regression analyses, stratified by interview type, examined associations with interview performance. RESULTS: The 4,993 applicants who completed 7,516 interviews included 931 (18.6%) UIM and 962 (19.3%) DA individuals; 3,226 (64.6%) had only 1 interview. Mean age was 24.4 (SD = 2.7); mean GPA and MCAT score were 3.72 (SD = 0.22) and 33.6 (SD = 3.7), respectively. Older age, female gender, and number of prior interviews were associated with better performance on both MMIs and TIs. Higher GPA was associated with lower MMI scores (z score, per unit GPA = -0.26; 95% CI = -0.45, -0.06) but unrelated to TI scores. DA applicants had higher TI scores (z score = 0.17; 95% CI = 0.07, 0.28) but lower MMI scores (z score = -0.18; 95% CI = -0.28, -0.08) than non-DA applicants. Neither UIM status nor MCAT score was associated with interview performance. CONCLUSIONS: These findings have potentially important workforce implications, particularly regarding MMI performance of DA applicants, and illustrate the need for other multi-institutional studies.

Reliability of Multiple Mini-Interviews and traditional interviews within and between institutions: a study of five California medical schools.

BACKGROUND: Many medical schools use admissions Multiple Mini-Interviews (MMIs) rather than traditional interviews (TIs), partly because MMIs are thought to be more reliable. Yet prior studies examined single-school samples of candidates completing either an MMI or TI (not both). Using data from five California public medical schools, the authors examined the within- and between-school reliabilities of TIs and MMIs. METHODS: The analyses included applicants interviewing at ≥1 of the five schools during 2011-2013. Three schools employed TIs (TI1, TI2, TI3) and two employed MMIs (MMI1, MMI2). Mixed linear models accounting for nesting of observations within applicants examined standardized TI and MMI scores (mean = 0, SD = 1), adjusting for applicant socio-demographics, academic metrics, year, number of interviews, and interview date. RESULTS: A total of 4993 individuals (completing 7516 interviews [TI = 4137, MMI = 3379]) interviewed at ≥1 school; 428 (14.5%) interviewed at both MMI schools and 687 (20.2%) at more than one TI school. Within schools, inter-interviewer consistency was generally qualitatively lower for TI1, TI2, and TI3 (Pearson's r 0.07, 0.13, and 0.29, and Cronbach's α, 0.40, 0.44, and 0.61, respectively) than for MMI1 and MMI 2 (Cronbach's α 0.68 and 0.60, respectively). Between schools, the adjusted intraclass correlation coefficient was 0.27 (95% CI 0.20-0.35) for TIs and 0.47 (95% CI 0.41-0.54) for MMIs. CONCLUSIONS: Within and between-school reliability was qualitatively higher for MMIs than for TIs. Nonetheless, TI reliabilities were higher than anticipated from prior literature, suggesting TIs may not need to be abandoned on reliability grounds if other factors favor their use.

Small group activities within academic communities improve the connectedness of students and faculty.

BACKGROUND: The University of California, San Diego, School of Medicine implemented a curriculum change that included reduction of lectures, incorporation of problem-based learning and other small group activities. Six academic communities were introduced for teaching longitudinal curricular content and organizing extracurricular activities. METHODS: Surveys were collected from 904 first- and second-year medical students over 6 years. Student satisfaction data with their sense of connectedness and community support were collected before and after the implementation of the new curriculum. In a follow-up survey, medical students rated factors that contributed to their sense of connectedness with faculty and students (n = 134). RESULTS: Students' perception of connectedness to faculty significantly increased following implementation of a curriculum change that included academic communities. Students ranked small group clinical skills activities within academic communities significantly higher than other activities concerning their sense of connectedness with faculty. Students' perception of connectedness among each other was high at baseline and did not significantly change. Small group activities scored higher than extracurricular activities regarding students' connectedness among themselves. CONCLUSIONS: The implementation of a new curriculum with more small group educational activities including academic communities enhanced connectedness between students and faculty and resulted in an increased sense of community.

Are self-identified "disadvantaged" students less likely to enter surgical residencies? A single-institution study.

BACKGROUND: Given more emphasis on training primary care physicians for underserved areas, we hypothesized that students self-identifying as "disadvantaged" would be less likely to pursue surgical training. METHODS: We retrospectively reviewed medical school data on students graduating 2005-2014. Students were stratified into "disadvantaged" and "nondisadvantaged". Data were recorded on age, grade point average, Medical College Admission Test (MCAT), gender, surgery grade, United States Medical Licensing Examination step 1 score, and residency match into a surgical field. A comparison of the proportion of students matching into a surgical field was assessed with chi-square test. Multivariate logistic regression was performed to assess the factors that predict the choice of general surgery versus another surgical field. RESULTS: Of the 1140 students who graduated during the study period, 219 (19.2%) students self-identified as "disadvantaged". Of all students, 158 (13.9%) chose a surgical field. The disadvantaged group was older at entry and had lower grade point average and total MCAT scores. Twenty-seven (12.3%) disadvantaged students chose a surgical residency versus 130 (14.1%) nondisadvantaged students (P = 0.56). On multivariate logistic regression, female gender (odds ratio [OR] = 3.9; 95% confidence interval = [1.9-8.3], P < 0.01), disadvantaged status (OR = 2.8 [1.1-7.1], P = 0.03), and United States Medical Licensing Examination step 1 score ≥ 227 (OR = 0.43 [0.21-0.88], P = 0.02) were significantly associated with matching into general surgery versus another surgical specialty. DISCUSSION: Although the disadvantaged cohort was older and had lower undergraduate GPAs and MCAT scores, the proportion of disadvantaged students matching into a surgical residency was not statistically different. To address the future shortage of general surgeons in underserved areas, increasing enrollment of "disadvantaged" students may alleviate the "surgical desert".

Evaluating a grading change at UCSD school of medicine: pass/fail grading is associated with decreased performance on preclinical exams but unchanged performance on USMLE step 1 scores.

BACKGROUND: To assess the impact of a change in preclerkship grading system from Honors/Pass/Fail (H/P/F) to Pass/Fail (P/F) on University of California, San Diego (UCSD) medical students' academic performance. METHODS: Academic performance of students in the classes of 2011 and 2012 (constant-grading classes) were collected and compared with performance of students in the class of 2013 (grading-change class) because the grading policy at UCSD SOM was changed for the class of 2013, from H/P/F during the first year (MS1) to P/F during the second year (MS2). For all students, data consisted of test scores from required preclinical courses from MS1 and MS2 years, and USMLE Step 1 scores. Linear regression analysis controlled for other factors that could be predictive of student performance (i.e., MCAT scores, undergraduate GPA, age, gender, etc.) in order to isolate the effect of the changed grading policy on academic performance. The change in grading policy in the MS2 year only, without any corresponding changes to the medical curriculum, presents a unique natural experiment with which to cleanly evaluate the effect of P/F grading on performance outcomes. RESULTS: After controlling for other factors, the grading policy change to P/F grading in the MS2 year had a negative impact on second-year grades relative to first-year grades (the constant-grading classes performed 1.65% points lower during their MS2 year compared to the MS1 year versus 3.25% points lower for the grading-change class, p < 0.0001), but had no observable impact on USMLE Step 1 scores. CONCLUSIONS: A change in grading from H/P/F grading to P/F grading was associated with decreased performance on preclinical examinations but no decrease in performance on the USMLE Step 1 examination. These results are discussed in the broader context of the multitude of factors that should be considered in assessing the merits of various grading systems, and ultimately the authors recommend the continuation of pass-fail grading at UCSD School of Medicine.

Repression of IFN-gamma expression by peroxisome proliferator-activated receptor gamma.

Peroxisome proliferator-activated receptors (PPARs) are ligand-activated transcription factors expressed in a wide variety of cells. Our studies and others have demonstrated that both human and murine T cells express PPARgamma and that expression can be augmented over time in mitogen-activated splenocytes. PPARgamma ligands decrease proliferation and IL-2 production, and induce apoptosis in both B and T cells. PPARgamma ligands have also been shown to be anti-inflammatory in multiple models of inflammatory disease. In the following study, we demonstrate for the first time that PPARgamma is expressed in both murine CD4 and CD8 cells and that PPARgamma ligands directly decrease IFN-gamma expression by murine and transformed T cell lines. Unexpectedly, GW9662, a PPARgamma antagonist, increases lymphocyte IFN-gamma expression. Transient transfection studies reveal that PPARgamma ligands, in a PPARgamma-dependent manner, potently repress an IFN-gamma promoter construct. Repression localizes to the distal conserved sequence of the IFN-gamma promoter. Our studies also demonstrate that PPARgamma acts on the IFN-gamma promoter by interfering with c-Jun activation. These studies suggest that many of the observed anti-inflammatory effects of PPARgamma ligands may be related to direct inhibition of IFN-gamma by PPARgamma.

18. Immune-mediated renal disease.

Immune-mediated renal diseases can be classified by the clinical syndromes they produce, by the attendant renal pathology, or by the dominant immune effector mechanism of renal injury. The major clinical syndromes produced by immune-mediated renal injury include the nephrotic syndrome, the nephritic syndrome, rapidly progressive glomerulonephritis, and acute renal failure. The notion of clinical syndromes facilitates diagnosis and treatment, but does not accurately define disease pathogenesis. In this summary, we discuss pathologically defined immune-mediated renal diseases under the clinical syndrome with which they are most frequently associated. There is overlap between the clinical syndromes, but the syndromes provide a useful framework. Relevant information regarding the proposed pathogenesis of disease entities is included under specific disease entities.

WY14,643, a PPAR alpha ligand, has profound effects on immune responses in vivo.

Peroxisome proliferator-activated receptors (PPARs) are ligand-activated transcription factors with diverse actions. PPARalpha and PPARgamma are expressed in different lymphocyte subpopulations. Recently, we have observed that PPARalpha ligands elicit augmented IL-4 expression in cultures of mitogen-activated splenocytes. The following studies were undertaken to characterize the in vivo effects of WY14,643, a PPARalpha ligand. Our studies demonstrate that oral administration of WY14,643 markedly reduces splenocyte number in immunized and nonimmunized C57BL/6 mice. Mice fed WY14,643 display impaired IgG responses to myelin oligodendrocyte glycoprotein peptide 35-55 (pMOG(35-55)), following immunization with pMOG(35-55)/CFA. Following in vitro restimulation with pMOG(35-55), splenocytes harvested from WY14,643-fed mice demonstrate impaired production of IFN-gamma, IL-6, and TNF-alpha despite similar proliferative responses. We also demonstrate higher expression of PPARalpha in B than T cells. Finally, to obtain an understanding of the cause of splenocyte depletion with fibrate therapy, we studied the effect of WY14,643 on apoptosis of activated splenocytes. WY14,643 in vitro induces apoptosis in lymphocytes and this effect appears to occur in a PPARalpha-independent manner. Thus WY14,643, a fibrate, is a profound immunosuppressive agent.

Regulation of cytokine expression by ligands of peroxisome proliferator activated receptors.

Peroxisome proliferator activated receptors (PPARs) are ligand-activated transcription factors with diverse actions including adipocyte differentiation and lipid metabolism. Recent studies have revealed anti-inflammatory activities, but the majority of these studies have been performed in monocyte/macrophages. In these studies, we investigate the effects of PPAR ligands in murine mitogen-activated splenocytes. Ciglitazone, a PPARgamma ligand, consistently decreased IFN-gamma and IL-2 production by mitogen-activated splenocytes and had modest effects on splenocyte proliferation. The effects of WY14,643, a representative of the fibrate class of PPARalpha ligands, on splenocyte proliferation and IL-2 levels are less marked than those observed with the PPARgamma ligand. In addition, treatment with WY14,643 and other fibrates led to marked increases in supernatant concentrations of IL-4. However, treatment with a potent and specific PPARalpha ligand (GW7,647) did not augment IL-4. Also, WY14,643 induced IL-4 expression in splenocytes from PPARalpha knockout mice, suggesting that the fibrate effect on IL-4 was largely through a PPARalpha-independent mechanism. This increase in IL-4 was associated with and causatively related to augmented expression of CD23 by CD45R/B220(+) cells. We also demonstrate that PPARgamma gene expression is up-regulated in T cells by mitogen activation, that it is positively regulated by IL-4 and WY14,643, and that it is blocked by anti-IL-4. Finally, we demonstrate that WY14,643 can modestly augment IL-4 promoter activity in a PPARalpha-independent manner. In concert, these findings support the roles of PPAR ligands in modulating inflammatory responses involving lymphocytes but also establish potent effects of the fibrate class of PPARalpha ligands on IL-4 expression that are receptor independent.

Effect of acute iNOS inhibition on glomerular function in tubulointerstitial nephritis.

BACKGROUND: Tubulointerstitial nephritis (TIN) is characterized by progressive inflammatory infiltrate of the renal interstitium, induction of cortical tubular inducible nitric oxide synthase (iNOS) and reductions in glomerular filtration rate (GFR). These studies were designed to examine the changes in glomerular hemodynamics 7 and 21 days after induction of TIN and to evaluate the effect of acute iNOS blockade on glomerular function in the early stages of this model. METHODS: TIN was induced by immunizing Brown Norway rats with renal tubular antigen in complete Freund's adjuvant (RTA/CFA). Control rats were immunized with CFA alone. Micropuncture and morphologic studies were performed 7 and 21 days after immunization. RESULTS: Histology revealed minimal peritubular and interstitial inflammation in the RTA/CFA group one week after immunization while extensive interstitial inflammation with few preserved superficial nephron was observed three weeks after RTA/CFA immunization. Micropuncture studies on day 7 in the RTA/CFA group revealed a significant reduction in single nephron GFR due to a profound reduction in nephron plasma flow and in the ultrafiltration coefficient. Studies performed on day 21 revealed that single nephron GFR (SNGFR), nephron plasma flow (SNPF) and the ultrafiltration coefficient had returned to the normal baseline value despite the severe reduction in GFR. To assess the role of increased nitric oxide production secondary to iNOS induction on the glomerular hemodynamic changes observed in the early stages of the disease, the iNOS blocker (l-N(6)-iminoethyl lysine, L-NIL) was administered IV (1 mg/h) in RTA/CFA rats and CFA rats. L-NIL had no effect in CFA rats but produced significant increases in GFR, SNGFR and SNPF in RTA/CFA rats. CONCLUSIONS: These results demonstrate that TIN is associated with a progressive reduction in GFR, which is likely the result of functional vasoconstriction and decreases in the ultrafiltration coefficient in the early stages of the disease and on a significant reduction in the number of functioning nephron in the later stages. Induction of iNOS with increased NO production actively participates in the functional changes observed in the early stages of the disease most likely by inhibiting normal endothelial NOS activity.