Surveying the Middle Ground: A Thematic Analysis of the Medical School Applications of Standard Performers.

INTRODUCTION: As gatekeepers to the medical profession, admissions committees make important decisions through the analysis of quantitative (e.g. test scores and grade point averages) and qualitative (e.g. letters of recommendation and personal statements) data. One area of the application that deserves additional study is the Work and Activities section, where students describe their extracurricular experiences. Previous research has found different themes that sometimes overlap in the applications of exceptional performing and low performing medical students, but it is unclear if these themes are present in the applications of standard performers. MATERIALS AND METHODS: An exceptional performing medical student is defined as one who was inducted into both the Alpha Omega Alpha Honor Medical Society and the Gold Humanism Honor Society. A low performing medical student is one who was referred to the Student Promotions Committee (SPC) where an administrative action was made. A standard performing medical student is defined as someone who was neither a member of an honor society nor referred to the SPC during medical school. Using a constant comparative method, the applications of standard performers who graduated from the Uniformed Services University between 2017 and 2019 was assessed using exceptional performer themes (success in a practiced activity, altruism, teamwork, entrepreneurship, wisdom, passion, and perseverance) and low performer themes (witnessing teamwork, embellishment of achievement, and description of a future event). The presence of novel themes was also assessed. The absolute number of themes and the diversity of themes were determined. Demographic data were collected (age, gender, number of Medical School Admissions Test [MCAT] attempts, highest MCAT score, and cumulative undergraduate grade point average), and descriptive statistics was performed. RESULTS: A total of 327 standard performers were identified between 2017 and 2019. No novel themes were found after coding 20 applications. All exceptional performer themes were identified in the population of standard performers. The low performing theme of embellishment of achievement was not found. Standard performers had a lower number of total exceptional performer themes and a lower diversity of exceptional performer themes compared to low and exceptional performers, but standard performers also had a lower number and less diversity of low performing themes compared to low performers. CONCLUSIONS: This study suggests that the diversity and frequency of exceptional performing themes in a medical school application may be useful in distinguishing between exceptional performers and other performers, though the small sample size limits quantitative conclusions. Low performing themes may be specific to low performers and thus could be useful to admissions committees. Future studies should include a larger sample size and could assess for predictive validity evidence of these exceptional performing and low performing themes through a blinded protocol.

Increasing Faculty Participation and Mentorship in Quality Improvement with an Experiential Four-Hour Workshop.

BACKGROUND: Graduate medical education programs lack enough faculty trained in quality improvement (QI). A major barrier to increasing the number of faculty competent in QI is insufficient time to engage in training. Research is missing on the effectiveness of short faculty development workshops to teach academic faculty QI principles and promote participation and mentorship in QI projects. OBJECTIVE: The authors assessed the ability of a four-hour experiential QI workshop to increase faculty proficiency in QI principles, enhance faculty involvement in QI, and improve resident mentorship in QI. METHODS: From 2016 to 2017, the authors conducted seven QI faculty development workshops at a large academic medical center with 12 ACGME training programs. We evaluated the workshop using pre- and post-workshop surveys, as well as six- and twelve-month follow up surveys. RESULTS: Sixty-five faculty participated in seven workshops over 13 months. All participants completed pre- and post-workshop surveys, while 38% (n = 25) responded to the six- and twelve-month follow up surveys. Overall, the workshop significantly increased confidence to lead and mentor residents on a QI project (25% pre vs. 72% post, p < .001), increased ability to teach QI (8% pre vs. 36% post, p < .001), increased participation in planning and decision making on a QI team (32% pre vs. 50% post, p = .002), and increased the mean number of QI projects implemented (.45 pre vs. 1.24 post; p < .05). CONCLUSION: A four-hour QI workshop is a quick and effective training method to develop academic faculty to teach and mentor residents in QI. The principles taught increased perceived knowledge, confidence in mentorship, and participation in QI.

Beyond Grade Point Averages and Medical College Admission Test Scores: A Thematic Analysis of Exceptional Performing Medical Student Applications.

This article was migrated. The article was marked as recommended. Introduction: Medical school admissions committees are tasked with selecting the best students for their institution and historically rely on grade point averages and Medical College Admission Test scores as measures for academic success. Yet research and expertise theory suggest that personal characteristics play a critical role in exceptional performance. Understanding the characteristics of exceptional performing medical students upon application to medical school could contribute to the holistic review process and selection decisions of medical universities. Methods: The purpose of this study was to identify themes in the American Medical College Application Service (AMCAS) application that reflect the characteristics of exceptional performing medical students when they applied to medical school. The authors completed an inductive thematic analysis of the primary AMCAS application of exceptional performing medical students. Selection to both Alpha Omega Alpha Honor Medical Society and the Gold Humanism Honor Society defined exceptional performance. Results/Analysis: 22 (4.5%) of 485 medical school graduates between 2017 and 2019 met criteria for exceptional performance. The authors identified seven themes from the AMCAS applications: success in a practiced activity, altruism, entrepreneurship, passion, perseverance, teamwork, and wisdom. Discussion: The seven identified themes were consistent with the personal characteristics associated with both expertise theory and the AAMC's core personal competencies for medical student success. By constructing an understanding of the personal characteristics exceptional student performers display in their applications to medical school, these themes offer an additional lens for medical school admission committees to assess a student's potential to be successful in medical school.

What Influences the Decision to Interview a Candidate for Medical School?

INTRODUCTION: Holistic review, in which medical schools seek to balance applicant attributes and experiences alongside traditional academic metrics in making admissions decisions, has been in place for over a decade. Medical school applicants and the admissions' community are still trying to understand the impact of holistic review on the composition of those medical schools choose to interview and accept. MATERIALS AND METHOD: The study cohort included all candidates who applied to Uniformed Services University of the Health Sciences (USU) in 2014, 2015, and 2016 (N = 8,920). We conducted logistic regression analysis to examine the associations between the sociodemographic, academic, and military service variables of applicants applying to the School of Medicine and offers for interview. RESULTS: Medical College Admission Test scores and undergraduate grade point averages were important in predicting who would receive an interview. Having military experience, being a woman, and being self-reported African American race also predicted a higher likelihood of receiving an interview invitation. For example, controlling for all other variables in the model, if an applicant had previous military experience, the odds of being invited for interview was about 4 times that of an applicant who had no previous military experience. Leave this for the text and discussion. The resulting pool of interviewed and accepted students more increasingly represented the Military Health Service population served. CONCLUSIONS: The use of holistic review generated a class with a composition different from that which would be predicted by Medical College Admission Test and grade point average alone. Further, holistic review produced an interview pool and class more representative of the wider Military Health Service beneficiary population. In the case of USU, holistic review allowed the school to better meet its mission to create a representative class able to "care for those in harm's way."

Anaphylaxis: Recognition and Management.

Anaphylaxis is a life-threatening systemic reaction, normally occurring within one to two hours of exposure to an allergen. The incidence of anaphylaxis in the United States is 2.1 per 1,000 person-years. Most anaphylactic reactions occur outside the hospital setting. Urticaria, difficulty breathing, and mucosal swelling are the most common symptoms of anaphylaxis. The most common triggers are medications, stinging insect venoms, and foods; however, unidentified triggers occur in up to one-fifth of cases. Coexisting asthma, mast cell disorders, older age, underlying cardiovascular disease, peanut and tree nut allergy, and drug-induced reactions are associated with severe or fatal anaphylactic reactions. Clinicians can obtain serum tryptase levels, reflecting mast cell degranulation, when the clinical diagnosis of anaphylaxis is not clear. Acute management of anaphylaxis involves removal of the trigger; early administration of intramuscular epinephrine; supportive care for the patient's airway, breathing, and circulation; and a period of observation for potential biphasic reactions. Only after epinephrine administration should adjunct medications be considered; these include histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon. Patients should be monitored for a biphasic reaction (i.e., recurrence of anaphylaxis without reexposure to the allergen) for four to 12 hours, depending on risk factors for severe anaphylaxis. Following an anaphylactic reaction, management should focus on developing an emergency action plan, referral to an allergist, and patient education on avoidance of triggers and appropriate use of an epinephrine auto-injector.

Military Occupational Disability Risk Surveillance: A Retrospective Cohort Study of Modifiable Risk Factors.

INTRODUCTION: Occupational disability among military service members is an important target for preventive screening. The specific aim of this study was to quantify disability risk levels among soldiers with selected risk factors (body mass index extremes, poor or absent physical fitness scores, and tobacco and opioid use) and combinations thereof, suggesting priorities for preventive actions. MATERIALS AND METHODS: This was a retrospective cohort study of 607,006 active-duty soldiers who served in the U.S. Army during 2011-2014. Official medical and administrative data were combined to produce a person-month-based panel dataset with identifiers removed. The subjects were observed longitudinally for incident disability (termed medical nonreadiness) during 1,305,618 person-years at risk. We employed Weibull parametric survival regression models to determine the adjusted medical nonreadiness hazard for selected variables. We then computed individual adjusted risk scores and the population proportions affected by risk factors and combinations thereof in postregression analyses. The project was approved by the Stanford University's Institutional Review Board and underwent secondary review by the Human Research Protections Office of the Defense Health Agency. RESULTS: During the observed time, 81,571 (13.4%) of subjects were found medically not ready. High or low body mass index, low or missing physical fitness test scores, tobacco use, and the highest levels of opioid use were each associated with increased adjusted hazards of medical nonreadiness. The hazards increased substantially when multiple risk factors were present, albeit while affecting reduced population proportions. CONCLUSIONS: We identified marked disability hazard increases, especially in association with opioid use and high body mass index. These factors, in addition to tobacco use and low physical fitness, are potential early prevention targets for clinicians who screen military service members.

Prevalence of Use and Perceptions of Electronic Smoking Devices in a US Army Infantry Division.

Introduction: The increasing interest in electronic smoking devices (ESDs) among consumers shows promise for ESDs as a less harmful alternative for smoking and possibly for smoking cessation. Limited data on prevalence of ESD use in the military are available and data on perceptions of ESD use have not yet been published within an active duty, military-specific population. The primary outcome of this study was to define the prevalence of ESD use in a US Army division. Methods: We surveyed 1,288 military service members (response rate 95%, n = 1,225) from the 25th Infantry Division, Schofield Barracks, HI, in late 2015, on smoking habits, ESD usage, and perceptions surrounding ESDs. Chi-squared and Fisher's exact tests were used to assess categorical associations between smoking status, ESD usage, socio-demographic factors, cessation strategies, and perceptions regarding ESDs. Results: The prevalence of current ESD use was 20%, whereas the prevalence of having ever used an ESD was 61%. The daily smoking rate of participants was 23%. Those with lower education, current smokers, and ex-smokers were the most likely to be using an ESD. Current smokers and ESD users had a more favorable perception of ESDs with regard to their utility and health effectiveness. Conclusions: There is a high prevalence of current and ever use ESD among active duty service members assigned to a US Army Infantry Division. Data from similar studies suggest that this rate is growing. The rates of ESD use in military populations should continue to be monitored as the clinical utility of these devices continues to be investigated.

Nutrition for oral health and oral manifestations of poor nutrition and unhealthy habits.

The availability of proper nutrients is critical for the growth, development, maintenance, and repair of healthy dentition and oral tissues. Deficiencies particularly relevant to the dental practice are those in folate and other B complex vitamins; vitamins A, C, and D; calcium; fluoride; and protein. A lack of these nutrients affects nearly every structure in the oral cavity, causing or contributing to scurvy, cleft palate, enamel hypoplasia, poor mineralization, caries, and other pathoses. Damage to the dentition can also be observed in individuals with unhealthy habits; for example, a diet high in sugars will promote processes such as demineralization and caries. Diabetes also can result from a poor diet and is associated with periodontitis and oral candidiasis. Finally, the use of tobacco products and excessive alcohol intake damage the dentition and contribute to a variety of oral diseases, including stomatitis, malnutrition, and squamous cell carcinoma. Knowledge of these relationships will enable the dentist to question patients about dietary habits and provide guidance to encourage a healthy lifestyle.

Evaluation of the Painful Eye.

Eye problems constitute 2% to 3% of all primary care and emergency department visits. Common eye conditions that can cause eye pain are conjunctivitis, corneal abrasion, and hordeolum, and some of the most serious eye conditions include acute angle-closure glaucoma, orbital cellulitis, and herpetic keratitis. The history should focus on vision changes, foreign body sensation, photophobia, and associated symptoms, such as headache. The physical examination includes an assessment of visual acuity and systematic evaluation of the conjunctiva, eyelids, sclera, cornea, pupil, anterior chamber, and anterior uvea. Further examination with fluorescein staining and tonometry is often necessary. Because eye pain can be the first sign of an ophthalmologic emergency, the physician should determine if referral is warranted. Specific conditions that require ophthalmology consultation include acute angle-closure glaucoma, optic neuritis, orbital cellulitis, scleritis, anterior uveitis, and infectious keratitis.

Emergency intraosseous access: a useful, lifesaving device used in afghanistan.

Intraosseous access is becoming a lifesaving procedure under emergency conditions in Afghanistan?s battlefield. The EZ-IO system (Vidacare, San Antonio, TX, USA) was successfully used in five patients in whom there was difficulty finding a peripheral venous access. The EZIO is an indispensable medical device to be used on the battlefield and during the evacuation of the wounded in a moving vehicle or helicopter.

The prevalence of vitamin B(12) deficiency in patients with type 2 diabetes: a cross-sectional study.

PURPOSE: The purpose of this study is to define the prevalence of vitamin B(12) deficiency in a type 2 diabetic population within a primary care practice. Metformin use and advanced age are associated with vitamin B(12) deficiency and often present in type 2 diabetic patients, yet the prevalence of vitamin B(12) deficiency in the diabetic population is unknown. METHODS: We conducted a cross-sectional study of 203 outpatient type 2 diabetic patients at a large military primary care clinic. Patients completed a survey and had B(12) levels measured. Patients with borderline B(12) levels also had methylmalonic acid and homocysteine levels drawn. Serum B(12) levels <100 pg/mL or serum B(12) levels of 100 to 350 pg/mL with elevation of serum methylmalonic acid >243 nmol/L or homocysteine >11.9 nmol/L defined B(12) deficiency. Descriptive statistics described frequency and means. chi(2) and student's t tests were used to analyze associations between categorical and continuous variables, respectively. Multivariate logistical regression identified covariates independently associated with B(12) deficiency. RESULTS: Twenty-two percent (n = 44) of diabetic patients had metabolically confirmed B(12) deficiency. Patients on metformin had lower serum B(12) levels (425.99 pg/mL vs 527.49 pg/mL; P = .012) and were at increased risk for B(12) deficiency (P = .04), as defined by a serum B(12) level <350 pg/mL. Prevalence of B(12) deficiency was significantly lower for patients using a multivitamin (odds ratio, 0.31; 95% CI, 0.15-0.63). CONCLUSIONS: Our results found a 22% prevalence of metabolically confirmed B(12) deficiency in the primary care type 2 diabetic population. Although further research needs to be performed to determine the clinical implications of our findings, B(12) deficiency should be considered in type 2 diabetic patients, especially those taking metformin. Furthermore, a daily multivitamin may protect against B(12) deficiency.