Imbalanced specialty representation of USMLE and NBME test writers.

PURPOSE: The United States Medical Licensing Examination (USMLE) is an examination series required for allopathic physician licensure in the United States (US). USMLE content is created and maintained by the National Board of Medical Examinations (NBME). The specialty composition of the USMLE and NBME taskforce members involved in the creation of examination content is currently unknown. METHODS: Using the 2021 USMLE and 2021 NBME Committees and Task Forces documents, we determined each member's board-certified primary specialty and involvement in test material development committees who we dubbed "test writers". Total active physicians by primary specialty were recorded from the 2020 Physician Specialty Data Report published by the Association of American Medical Colleges (AAMC). Descriptive statistics and chi-square analysis were used to analyze the cohorts. RESULTS: The USMLE and NBME test writer primary specialty composition was found to be significantly different compared to the US active physician population (USMLE χ2[32] = 172, p < .001 and NBME χ2[32] = 200, p < .001). Only nineteen specialties were represented within USMLE test writers, with three specialties being proportionally represented. Two specialties were represented within NBME test writers. Obstetrics and Gynecology physicians were proportionally represented in USMLE but not within NBME test writers. Internal Medicine (IM) accounts for the largest percentage of all USMLE test writers (60/197, 30%) with an excess representation of 31 individuals. CONCLUSIONS: There is an imbalance in the specialty representation of USMLE and NBME test writers compared to the US active physician population. These findings may have implications for the unbiased and accurate portrayal of topics in such national examinations; thus, future investigation is warranted.

Analysis of Oncology and Radiation Therapy Representation on the National Board of Medical Examiners Official Practice Material for the United States National Standardized Medical Board Examinations.

Radiation therapy (RT) is a critical component of multidisciplinary cancer care, but has inconsistent curricular exposure. We characterize the radiation oncology (RO) content on the standardized undergraduate medical examinations by comparing its context and prevalence with other domains in oncology. National Board of Medical Examiners (NBME) self-assessments and sample questions for the United States Medical Licensing Exam (USMLE) Steps 1-3 and NBME clinical science shelf examinations were accessed (n = 3878). Questions were inductively analyzed for content pertaining to oncology and treatment modalities of RT, systemic therapy (ST), and surgical intervention (SI). Questions were coded using USMLE Physician Tasks/Competencies and thematic analysis. Descriptive statistics and analyses using the Kruskal-Wallis test are reported. A total of 337 questions (8.6%) within the USMLE and shelf exams included oncology content, with 101 questions (2.6%) referencing at least one cancer treatment modality (n = 35 RT, 45 ST, 57 SI). Treatment questions were more common on USMLE Step 2 CK (n = 35/101, 32%) compared to Step 1 (n = 23/101, 23%) and Step 3 (n = 8/101, 8%) (p < 0.001). RT was significantly less likely to be the correct answer (2/35, 6%) compared to ST (4/45, 9%) and SI (18/57, 32%) (p = 0.003). Therapeutic oncology questions are uncommon on the examination material, with an under-representation of radiation-related content, and contextual bias favoring surgical approaches. We advocate for greater RO involvement in the content creation of such examinations to help trainees better understand multidisciplinary cancer care.

Applicant and Program Director Perceptions of Second Look Events During the 2023 Radiation Oncology Residency Match.

Purpose: Virtual radiation oncology (RO) residency interviews may impair applicant and program evaluation. Second look events (SLEs) exist; however, the frequency, nature, and implications are unknown. We surveyed applicants and program directors (PDs) to characterize the 2023 RO Match SLEs and assess perspectives. Method and Materials: An online, anonymous survey was distributed to 2023 RO Match applicants and American College of Graduate Medical Education-accredited RO PDs post-Match. Number and percentage are reported as response per question. Likert-type scores (1, strongly agree; 5, strongly disagree) are reported as median, IQR. Results: Responses were received from 51 of 246 applicants (21%) and 52 of 88 PDs (59%). Forty applicants (87%) were offered in-person and virtual SLEs; 20 (51%) and 17 (44%) applicants were invited to 1 to 3 and 4 to 6 events, respectively. Most invited applicants attended none (21, 54%). Applicants reported that all (21, 54%) or some (16, 41%) programs communicated intentions to finalize rank order lists (ROLs) before SLEs. Most applicants (29, 74%) agreed that SLEs were optional without ROL consequences (median, 2, IQR 1-3). Applicants declined in-person SLEs due to city/facility indifference (10, 43%), finances (10, 43%), and logistics (9, 39%). Most (12, 86%) in-person SLE attendees agreed that SLEs influenced their ROL (median, 2, IQR 1-2). Nineteen PDs (40%) reported offering SLEs, with 18 of 19 being in-person. PDs who did not offer SLEs cited ethical concerns (13, 45%) and institutional policies (11, 38%). All PDs reported that SLEs were optional, and 18 of 19 explained that the SLE would be without ROL consequences. SLEs mostly occurred in February before (11, 58%) and after (15, 79%) ROL submission. Conclusions: In-person SLEs occurred during Match 2023. All PDs considered SLEs optional which was trusted by most applicants. Attendance at in-person SLEs influenced applicants' ROLs; however, finances and logistics impaired applicant attendance. Further work is needed to appreciate SLE implications and ensure equitable residency recruitment.

Trimodal Therapy Using an MR-guided Radiation Therapy Partial Bladder Tumor Boost in Muscle Invasive Bladder Cancer.

Purpose: Bladder preservation with trimodal therapy (TMT; maximal tumor resection followed by chemoradiation) is an effective paradigm for select patients with muscle invasive bladder cancer. We report our institutional experience of a TMT protocol using nonadaptive magnetic resonance imaging-guided radiation therapy (MRgRT) for partial bladder boost (PBB). Methods and Materials: A retrospective analysis was performed on consecutive patients with nonmetastatic muscle invasive bladder cancer who were treated with TMT using MRgRT between 2019 and 2022. Patients underwent intensity modulated RT-based nonadaptive MRgRT PBB contoured on True fast imaging with steady state precession (FISP) images (full bladder) followed sequentially by computed tomography-based RT to the whole empty bladder and pelvic lymph nodes with concurrent chemotherapy. MRgRT treatment time, table shifts, and dosimetric parameters of target coverage and normal tissue exposure were described. Prospectively assessed acute and late genitourinary and gastrointestinal (GI) toxicity were reported. Two-year local control was assessed with Kaplan-Meier methods. Results: Seventeen patients were identified for analysis. PBB planning target volume margins were ≤8 mm in 94% (n = 16) of cases. Dosimetric target coverage parameters were favorable and all normal tissue dose constraints were met. For MRgRT PBB fractions, median table shifts were 0.4 cm (range, 0-3.15), 0.45 cm (0-2.65), and 0.75 cm (0-4.8) in the X, Y, and Z planes, respectively. Median treatment time for MRgRT PBB fractions was 9 minutes (range, 6.9-17.4). We identified 32 out of 100 total MRgRT fractions that may have benefitted from online adaptation based on changes in organ position relative to planning target volume, predominantly because of small bowel (13/32, 41%) or rectum (8/32, 25%). Two patients discontinued RT prematurely. The incidence of highest-grade acute genitourinary toxicity was 1 to 2 (69%) and 3 (6%), whereas the incidence of acute GI toxicity was 1 to 2 (81%) and 3 (6%). There were no late grade 3 events; 17.6% had late grade 2 cystitis and none had late GI toxicity. With median follow-up of 18.2 months (95% CI, 12.4-22.5), the local control rate was 92%, and no patient has required salvage cystectomy. Conclusions: Nonadaptive MRgRT PBB is feasible with favorable dosimetry and low resource utilization. Larger studies are needed to evaluate for potential benefits in toxicity and local control associated with this approach in comparison to standard treatment techniques.

Delivery of Online Adaptive MRI-Guided Radiation Therapy for a Deaf Patient.

MRI-guided radiation therapy (MRgRT) enables real-time imaging during treatment and daily online adaptive planning. It is particularly useful for areas of treatment that have been previously excluded or restricted from ablative doses due to potential damage to adjacent normal tissue. In certain cases, ablative doses to metastatic lesions may be justified and treated with MRgRT using video-assisted gated breath-hold adjustments throughout delivery. The workflow relies on patient biofeedback and auditory cues. A 74-year-old deaf male with a history of prostate cancer status post prostatectomy was found to have an enlarged cervical lymph node, which was excised with histopathology demonstrating Merkel cell carcinoma. Approximately one year after treatment with two cycles of pembrolizumab, which was subsequently discontinued due to toxicity, surveillance imaging demonstrated an enlarging left adrenal nodule. It was initially stable for an additional seven months with pembrolizumab rechallenge but was again found enlarged on subsequent imaging. The patient underwent MRg stereotactic body radiation therapy (MRgSBRT) to a total dose of 60 Gy in five fractions to this isolated site of progression. The patient was equipped with mirrored glasses to view the tracking structure with respect to gating the boundary structure, and the traditional reliance on verbal cues for coaching was reimagined to rely on visual cues instead. Follow-up positron emission tomography/CT (PET/CT) two weeks after treatment demonstrated interval resolution of the left adrenal metastatic nodule and a return to symmetric bilateral adrenal gland metabolic activity. The necessary MRgSBRT treatment for single metastatic lesions near normal tissue structures relies on verbal cues and coaching. However, deaf patients are unable to receive this treatment according to the traditional workflow model. Unique opportunities exist for the implementation of culturally competent care for the Deaf community, relying more heavily on visual cues, in radiation oncology practice.

Social Determinants, Risk Factors, and Needs: A New Paradigm for Medical Education.

COVID-19 and the escalation of racism and bias that has come in its wake have had a devastating impact on health professions students. In addition to academic challenges and personal health risks, aspects of students' lives that have often gone unnoticed or inadequately addressed have come to light. Financial constraints that impact access to housing and food, neighborhood safety in light of the spike in hate crimes, and the bias inherent in the continuum from premedical education to undergraduate and graduate medical education are some examples. The authors believe that to better understand students' lived experiences and determine how to best support them, the social determinants of health framework should be applied. This framework, the social determinants of education, encompasses concepts such as social risk factors and social needs in an effort to focus more intentionally on what can be done at a policy, institutional, and individual level. In response to the pandemic, the authors expanded their appreciation of students' risk factors and needs by advancing the scope and refining the definitions of 3 key determinants: from well-being to the power of individual and communal resilience, from equity to centering racial justice, and from student health to public health and infection prevention. The authors propose applying this same paradigm to the lived experiences of staff in medical education, whose needs are often neglected in favor of students and faculty, and who, in many cases, were the most negatively impacted by COVID-19 of all the constituents in an academic health center.

Summer Without Shelter in Tampa During COVID-19.

Shelter-in-place orders enacted during the 2020 COVID-19 pandemic were impossible to abide by for some persons without shelter in Tampa, Florida. This narrative considers themes of community, public health, and material conditions of humanity and dignity in a photographic investigation of life among persons for whom the prevailing adage "safer at home" did not apply.

Online Forums and the "Step 1 Climate": Perspectives From a Medical Student Reddit User.

Reddit is a popular content aggregator and discussion website that plays an important role in shaping medical student culture and study habits. The forum r/medicalschool, in particular, provides a distilled view into contemporary U.S. medical students' attitudes and deteriorating relationship to their home institutions' educators and curricula. As a national discussion on United States Medical Licensing Examination Step 1 reform emerges, the role of forums like r/medicalschool in shaping a "Step 1 climate" via the design and dissemination of prescriptive Step 1 study regimens based on commercially available resources and crowdsourced flash card decks goes largely unseen and undiscussed by medical educators. This Invited Commentary aims to introduce medical educators to these forums, highlight the common attitudes borne out of them, and contextualize one popular proposal for Step 1 reform-shifting to a pass/fail exam-within the author's experience as an online forum insider.