United States

Abstract Title 

The Impact of White Coat Ceremonies on Physician Professionalism 



Background 

For first-year medical students, reciting the Hippocratic oath and donning the medical white coat during the white coat ceremony (WCC) is a common practice among medical schools in the United States. The first WCC was organized by the Arnold P. Gold Foundation, a nonprofit organization that sought to humanize healthcare through the White Coat Ceremony. Before starting medical school, the WCC is a defining moment in commencing the journey of an aspiring physician. During this event, first-year medical students recite the Hippocratic Oath--stating a doctor&#39;s core values and responsibilities. 



Methods 

First- and second-year California University of Science and Medicine (CUSM) medical students were evaluated with a survey before and after attending their WCC to assess student professionalism. This survey included a 6-point Matrix Likert Scale of ACGME core competencies, as well as multiple-choice and free-response questions. Pre- and post-surveys were compared using paired t-tests. 



Results 

The average Hippocratic oath score increased from 3.85 to 4.58 (p = 0.01). 24% of students ranked their “understanding of professionalism” higher post-WCC. Most respondents (81%) either strongly agreed or agreed that the WCC instills professionalism after attending the WCC. In a free response question regarding “words associated with WCC”, the word “respect” had the most responses (n=26 and 20) pre and post WCC respectively. Pre-WCC, celebration (12), tradition (8), and achievement (7) were the most common responses. Post-WCC, celebration (11), social event (8), initiation (7). Several negative adjectives included: “indoctrinating”, “overrated”, “self-aggrandizing”, “self-congratulatory”, “elitist”, and “pretentious” (2). 



Conclusion 

The WCC significantly increases students&#39; knowledge of the Hippocratic oath and affects student perspectives on professionalism.

AMA Research Challenge 2024 

The Impact of White Coat Ceremonies on Physician Professionalism

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AMA Research Challenge 2022

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Abstract Title 

The Impact of White Coat Ceremonies on Physician Professionalism 



Background 

For first-year medical students, reciting the Hippocratic oath and donning the medical white coat during the white coat ceremony (WCC) is a common practice among medical schools in the United States. The first WCC was organized by the Arnold P. Gold Foundation, a nonprofit organization that sought to humanize healthcare through the White Coat Ceremony. Before starting medical school, the WCC is a defining moment in commencing the journey of an aspiring physician. During this event, first-year medical students recite the Hippocratic Oath--stating a doctor's core values and responsibilities. 



Methods 

First- and second-year California University of Science and Medicine (CUSM) medical students were evaluated with a survey before and after attending their WCC to assess student professionalism. This survey included a 6-point Matrix Likert Scale of ACGME core competencies, as well as multiple-choice and free-response questions. Pre- and post-surveys were compared using paired t-tests. 



Results 

The average Hippocratic oath score increased from 3.85 to 4.58 (p = 0.01). 24% of students ranked their “understanding of professionalism” higher post-WCC. Most respondents (81%) either strongly agreed or agreed that the WCC instills professionalism after attending the WCC. In a free response question regarding “words associated with WCC”, the word “respect” had the most responses (n=26 and 20) pre and post WCC respectively. Pre-WCC, celebration (12), tradition (8), and achievement (7) were the most common responses. Post-WCC, celebration (11), social event (8), initiation (7). Several negative adjectives included: “indoctrinating”, “overrated”, “self-aggrandizing”, “self-congratulatory”, “elitist”, and “pretentious” (2). 



Conclusion 

The WCC significantly increases students' knowledge of the Hippocratic oath and affects student perspectives on professionalism.

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Background 
The arts and humanities are well acknowledged for their ability to foster creativity, empathy, communication, and reducing physician burnout, but medical education has only taken small steps towards formal integration. As cited by an AAMC 2020 report The Fundamental Role of the Arts and Humanities in Medical Education: “the arts and the humanities play a unique and not fully realized role in this educational process, and we strongly encourage increased integration of the arts and humanities into curricula.” The Medical Humanities initiative (MHI) provides more formal opportunities to engage with the medical humanities throughout medical education.

Methods
The MHI incorporates humanities-based teaching at the Warren Alpert Medical School of Brown University (WAMS) through (1) wellness focused lunch sessions that engage students and faculty/staff in art forms including movement, music, and visual art; (2) a year-long pre-clinical elective course (PCE) that offers lectures from leaders in the medical arts and humanities; (3) established arts-based curriculum from Brown’s Internal Medicine Residency Arts and Medicine Track into WAMS clinical skills curriculum; (4) a committee of both undergraduate and graduate students that provides opportunities for leadership and mentorship from physicians and scholars working in medical humanities; and (5) the integration of disparate events and groups in the Providence area into a centralized resource/hub, facilitating student access and scholarly collaboration.

Results
In January 2024, the MHI held an introductory event at WAMS to highlight its mission, with one-third of WAMS students in attendance. Qualitative and quantitative feedback gathered in a post-event survey demonstrated enthusiasm for more formal exposure to the medical humanities as part of their education with 97% of students indicating interest in future lunch and learn sessions and 54.5% of students interested in taking a PCE on the subject. Upon implementation in 2024-2025, the Initiative will continue to collect metrics to characterize curriculum impact, including the Brief Resilience Scale and Subjective Happiness Scale, which were previously used by the Brown Arts & Medicine Track for Internal Medicine Residents to assess the impact of medical humanities programming on resident wellness and burnout. 

Conclusion
The MHI has received strong initial support from current medical students, residents, faculty, and deans. The Initiative offers a unique opportunity to strengthen the medical humanities presence at Brown, with the ultimate goal of fostering scholarship and leadership opportunities for students, while simultaneously improving student wellness and strengthening the ability of future physicians to provide empathetic care. 


The Value of Medical Humanities Education in Medical Student Training

Background
Medical school introduces unique challenges to romantic relationships and future life or personal planning. While research on relationships exists for physicians, there remains a significant gap in understanding romantic relationships among medical students. To address this gap, the University of Miami Miller School of Medicine (UMMSM) Wellness Advisory Council initiated a multi-institutional survey study as a student-led wellness initiative.

Methods
An anonymous Qualtrics survey covering demographics and history of romantic relationships was distributed to UMMSM and Tulane medical students via email. Outcomes were analyzed to discern differences among students in relationships with partners in medicine, with partners outside medicine, and not in relationships.

Results
A total of 326 out of 1564 medical students (21% response rate) completed the survey. Relationship status indicated that 67% were currently in a romantic relationship, while 9% reported no prior relationship experience. Of the 326 respondents, 27% were in relationships within medicine (WM), 40% were in relationships outside medicine (OM), and 33% were not in a relationship (NR).

For WM, on a scale of 1-10 (1 = the least, 10 = the most), the average score for their partner’s support for their medical education was 9.73, family’s support of the relationship was 9.11, and satisfaction for the relationship was 8.60. For OM, the scores were 9.50, 9.13, 8.68, respectively.

For NR, 72% were actively seeking relationships, primarily through friends, dating apps, and social outings. On a scale of 1-10, the average score for the ease of finding time for a relationship was 3.01 and their satisfaction with the search was 2.64. Those not seeking relationships cited reasons like poor timing, career focus, and lack of good options.

No significant differences between WM and OM were found when comparing family’s support and satisfaction with the relationship. However, there was a significant difference in partner’s support of their medical education (p = 0.03).

Conclusion
Our study found that medical students generally have high relationship satisfaction despite the challenges of medical school. Both WM and OM students reported strong family support. However, there was a significant difference in perceived support from partners for student’s medical education. Schools should integrate wellness programs to help partners outside of medicine better understand these challenges to bridge the gap. For single students, there is a clear demand for relationships, suggesting that schools could enhance student wellness by facilitating relationship-forming social events.

To Date Within Medicine or Outside Medicine? A Multi-Institutional Survey Study

Background: As competition for medical school admission intensifies, there is greater focus on the hidden curriculum—informal lessons learned during medical training that influence patient care, burnout resilience, and professional identity. Anticipatory socialization, the preliminary adoption by students of beliefs and behaviors perceived as essential for medical school success before matriculation, plays a crucial role in this process.

Anticipatory socialization impacts medical student and resident development, but limited research exists on its impact on pre-medical students' identity formation. This early identity shapes future professional behavior. This study explores how anticipatory socialization influences pre-medical students’ professional identity formation, focusing on how this process affects volunteering. Moreover, through the framework of self-determination theory, a general motivation theory, this study examines how motivational shifts influenced by anticipatory socialization impact intrinsic motivation for volunteering among pre-medical students.

Methods: Thirteen undergraduate, self-described pre-medical students from a North American university, who recently volunteered in a pre-medical capacity, participated in a semi-structured interview (September - November 2021). Open-ended questions explored their volunteer roles and the influence of their pre-medical identity on volunteering. Interviews were audio-recorded, transcribed, and thematically analyzed using content analysis within the framework of self-determination theory. Emerging themes in volunteering motivations, mindset changes due to the pre-medical identity, and the role of volunteering in medical school admissions were grouped into typologies, refined through group discussion.

Results: Thirteen semi-structured interviews were analyzed, revealing three major themes with eight subthemes. The first theme, volunteering motivation, included subthemes on motivations and goals. The second theme, the role of volunteering, had subthemes on lessons learned, challenges, and how volunteering should be evaluated in medical school applications. The third theme, the impact of pre-medical identities on volunteering, included subthemes on the impact of pre-medical identities, volunteering intentions, and the causes of pre-medical culture. Participants described a shift from intrinsic to extrinsic motivation for volunteering, before matriculation, due to anticipatory socialization, driven by the loss of self-determination theory’s three-factor structure (autonomy, competence, and relatedness) and various external factors.

Conclusion: In this study, anticipatory socialization among pre-medical students in North America, driven by peer competition, ambiguity in the medical school admissions process, and perceived expectations, caused a shift, based on self-determination theory, from intrinsic to extrinsic motivation for volunteering before matriculation. This shift is largely perceived by students as detrimental, with a return to intrinsic motivation seen as beneficial.

Volunteerism in Pre-Medical Education: Anticipatory Socialization's Role in Professional Identity Development

Background
Health professional organizations use lobbying to influence legislation that impacts patient care and their respective fields. Physician professional organizations (PPOs) are societies and associations that promote profession advancement through avenues such as research, practice guidelines, and continued medical education. PPOs spend lobbying dollars to advocate for specific interests, which vary by specialty, but research is lacking regarding lobbying patterns across PPOs. We sought to identify and quantify trends in lobbying spending with a focus on medical versus surgical PPOs. 

Methods
We extracted publicly available lobbying data from OpenSecrets (https://www.opensecrets.org) focusing on PPOs. We excluded coalitions, commercial groups, private practices, and all non-physician organizations. PPOs were further categorized as medical, surgical, or overlapping. We determined annual lobbying spending from 2014-2023 for each category and adjusted dollar values to 2023 USD using the Consumer Price Index inflation calculator. We used physician data from the American Association of Medical Colleges (AAMC) to calculate lobbying spending on a per-physician basis. A Mann-Kendall test was used to describe temporal trends in lobbying. 

Results
Over the study period, median spending by health professionals was $108 million/year, with PPOs contributing $71 million/year (65%). Overall, lobbying spending by health professionals trended downward but not significantly (p=0.06). In contrast, we found a significant downward trend in lobbying spending by PPOs over time (p<0.01). Within PPOs, lobbying spending was $32 million/year (45%) by medical specialty organizations and $12 million/year (16%) by surgical specialty organizations (10-year median values). PPOs in the overlapping category made up $27 million/year (39%) (median). Medical specialty organizations showed a significant downward trend over time in spending (p=0.04), while lobbying by surgical specialty organizations did not significantly change (p=0.09). PPO lobbying spending on a per-physician basis was $78/year for all physicians, $48/year for medical specialists, and $81/year for surgeons (median values). There were 521 lobbyists/year representing PPOs, with 352 (68%) representing medical specialties, 93 (18%) representing surgical specialties, and 79 (15%) in the overlapping category. 

Conclusion
In this study, we found that overall lobbying by health professional groups has remained stable. However, spending by PPOs and specifically those representing medical specialties have significantly decreased over time. Notably, although surgical specialty organizations made up a smaller percentage of total lobbying, their spending on a per-physician basis was generally higher. These findings assist in better understanding the complex intersection of lobbying and physician advocacy, while informing future efforts to evaluate priority issues for physician organizations.

A 10-Year Comparative Analysis of Medical and Surgical Specialty Lobbying

Background 
Disparities in health outcomes are well documented among racial and ethnic minority groups (REMG). However, broad and diverse inclusion in clinical trial research participation remains a national problem. Historically, clinical studies have not been inclusive of REMG. This study aims to identify barriers hindering ethnic and minority groups in the metropolitan area of Portland, Oregon from participating in clinical trials.  

Methods 
Adult residents aged 18 years or older within the metropolitan Portland, Oregon area were surveyed in public places throughout the city and surrounding suburbs. Each participant responded to a demographic survey and 10-question inquiry regarding their opinions of clinical trials. Answers were documented by interviewers and audio recorded for thematic analysis. Responses were grouped into common themes and ranked by frequency. Chi-squared analyses were performed to determine differences between groups. 

Results 
A total of 206 participants were surveyed, with a response rate of 60%. The majority of participants were female (55.8%), aged 18-24 years old (44.7%), or 35-55 (27.9%) years old. Around 40.9% were white, 33.7% Asian, 12% Black or African American, 28% mixed race, and 15% unknown. Education levels among participants included high school degree (26.5%), some college without a degree (17.8%), associate’s degree (25%), bachelor’s degree (26.9%), and graduate degree (15.4%).  

The majority of respondents (70%) had a positive view of clinical trials and cited benefits for society and advancements in medicine and science. However, approximately 30% expressed negative views, citing a lack of real-world benefits, participation barriers, safety concerns, and significant risks as reasons for reluctance to volunteer for a clinical trial. 

Notably, positive opinions of clinical trials among minority groups (66%), including Black and African Americans (57%), were significantly lower than those of white residents (79%, p=0.00001). Significantly, nonwhite participants when compared to white respondents (10%), including Asian (20%) and Mixed race (30%) respondents, showed less interest in participating in clinical (17%, p=0.016). 

Conclusion 
In the metropolitan area of Portland, residents had an overall favorable view of clinical trials. However, significant disparities exist in how minority groups perceive clinical trials. White and Caucasian residents were more likely to view clinical trial participation positively compared to minority groups. There is a considerable difference in interest among minority groups, who demonstrate lower levels of participation compared to white respondents, highlighting the need to investigate these barriers. Future studies are needed to better understand these disparate perceptions and improve clinical trial participation among minorities. 

A qualitative study: attitudes towards clinical trial participation among residents of Portland, OR

Background: Lead contamination from hunting ammunition in game meat has been a recognized issue for decades, with significant environmental and health impacts. Despite regulations reducing lead use in certain ammunition types, lead bullets remain common in deer hunting, leading to potential health risks when this meat is donated to food banks. This study aims to address the practice and risks associated with donated game-hunted meat within the Ohio food bank system, focusing on stakeholders' roles, awareness, and existing safety measures.

Methods: Semi-structured telephone interviews were conducted with 26 stakeholders, including meat processors, meat distribution organizations, state meat inspectors, food banks, and food pantries in Ohio and Minnesota. Participants were recruited via convenience sampling and interviewed about their knowledge and practices related to lead contamination in donated game meat. The interviews, averaging 25 minutes in length, covered topics such as the use of lead ammunition, food safety practices, and organizational safety measures. The data was systematically coded and analyzed using content analysis to identify patterns and themes.

Results: Significant disparities in awareness and safety measures were found between Ohio and Minnesota stakeholders. Ohio food banks and pantries exhibited minimal awareness of lead contamination risks (0/18 participants) and relied heavily on meat processors for safety, with few processors employing comprehensive safety measures beyond basic bullet removal. In contrast, Minnesota implements a robust system involving mandatory x-ray screening funded by hunting license surcharges. This system significantly reduces the risk of lead contamination, though it faces financial and logistical challenges. Notably, approximately 5-15% of donated meat in Minnesota is discarded annually due to lead contamination. Food banks and pantries in Ohio expressed a strong willingness to learn and implement safety changes when informed about the risks.

Conclusion: This study reveals a critical health risk within the Ohio food bank system due to lead-contaminated game meat. Increased awareness and targeted interventions, such as warning labels and improved processing practices, are essential to mitigate this risk. The willingness of Ohio stakeholders to implement changes underscores the need for educational campaigns and policy discussions to enhance food safety. By adopting measures similar to those in Minnesota, Ohio could improve the safety of donated game meat. Collaborative efforts between states could further refine these interventions and promote nationwide food safety standards.


Addressing Donated Lead-Contaminated Meats within the Ohio Food Bank
System

The subject of maternal mortality and maternal health has been a topic of discussion for centuries but has recently gained traction in population health initiatives within the late 20th century. The United States has one of the highest rates of maternal mortality of all high-income countries, however, studies show that four in five maternal deaths in this country are preventable. Pregnant people of color and low-income mothers are overrepresented within these statistics, a detail that has been prevalent for decades. High maternal death rates are being perpetrated by the
growing nationwide shortage of the maternity workforce, following the rising number of restrictions to reproductive health care in many states. There have been many attempts to try and lower these numbers, but many of them have failed to gain much traction.
To alleviate these numbers and address the overall issue, I propose applying an add-on payment through Medicaid mandating that providers give comprehensive education to their pregnant patients. This would incentivize maternity workforce personnel to put aside time to properly inform families of potential complications and resources that are readily available to them. Another recommendation would be that states reinforce that all maternity care providers receive anti-bias and anti-racism training as part of a curriculum. Quality of care from providers
would increase drastically by enhanced patient trust in the medical workforce and any implicit biases potentially impeding on effective care from providers would be minimized. Innovative demonstration projects overseen by the Center for Medicare and Medicaid could also be implemented in select states to establish these recommendations. Pushing forth these initiatives would help many families and relieve the stress of maternal mortality within our healthcare system.

Addressing the Crisis of Maternal Mortality in the United States

Purpose
Telehealth has become a mainstay of modern healthcare, post-COVID-19 pandemic era. Telehealth has increased access to healthcare providers across various regions, potentially reducing access disparities. Currently no studies exist evaluating the impact of telehealth on access equity in thoracic surgery. This paper aims to assess if telehealth increases access to thoracic oncologic surgery in disadvantaged communities.

Methods
A retrospective single institution review of thoracic surgery patients with an oncologic indication from March 2018 to November 2022 was conducted. Patients were stratified into office or telehealth groups based on the type of their first preoperative consultation visit. Patients being assessed for esophageal malignancy or mediastinal staging alone were excluded. Demographic data included age, sex, location by county, and state. Primary outcomes were median Area Deprivation Index (ADI) for state deciles and national percentiles for in-office and telehealth patients. The Area Deprivation Index (ADI) is a ranking of socioeconomic disadvantaged neighborhoods at the state or national level with consideration for factors such as income, education, employment status, and housing. Mann-Whitney U tests were used to analyze the ADI difference between groups. 

Results
759 patients met inclusion criteria, including 376 in office and 383 telemedicine. All telemedicine visits were audio only and conducted over the phone. There were no demographic differences between groups based on age (p=0.3) or sex (p=0.9). There was a total of 62 unique counties represented among all patients in this cohort. The majority of patients resided in Oregon (628/759, 82.74%) and Washington (108/759, 14.23%). Median ADI for national percentiles and state deciles can be seen in Table 1. The median ADI of telehealth patients was significantly higher than that of in office patients (34 v. 32, p<0.01). Similar results for telemedicine and in-office patients were found when evaluating Oregon specific ADIs (5 v 6, p<0.01). There was no difference in State ADIs for patients from Washington (p = 0.156).

Conclusions
Overall, patients in the telemedicine group had a higher disadvantaged rating than their in-office counterparts nationally and in Oregon. Telemedicine improves access to thoracic surgeons for patients from socioeconomically disadvantaged neighborhoods, addressing the unequal distribution of physicians and healthcare systems in these areas. Further studies should be conducted to evaluate the role of telehealth in increasing health equity in thoracic surgical cancer care.

Addressing the Inequities in Thoracic Surgery: How Telemedicine is Levelling the Playing Field

Background: The utilization of Nurse Practitioners (NPs) has emerged as a potential solution to address physician shortages, serve underserved areas, and manage high patient volumes in primary care settings. However, the scope of practice (SOP) laws for NPs varies significantly across states. Twenty-eight states and Washington D.C. allow full practice authority; twelve states have reduced practice regulations; and eleven states have restricted practice. This variation in regulatory frameworks, coupled with the cost-effectiveness of NPs compared to physicians, necessitates a comprehensive examination of the impact of NP SOP laws on health outcomes. As the United States faces an impending physician shortage, understanding the relationship between NP SOP and healthcare quality becomes crucial for informed policy decisions and effective workforce planning in primary care.

Methods: A legal epidemiology study was conducted to analyze the impact of Nurse Practitioner (NP) scope of practice (SOP) laws across five U.S. states: Oregon, Washington, California, Texas, and Illinois, representing a spectrum of regulatory frameworks. The study began by defining the research question on how NP SOP laws affect primary care outcomes. A comprehensive legal mapping process followed, involving the collection and coding of relevant laws from state legislatures to identify patterns and variations. Primary care health outcome data, including wait times, provider-to-population ratios, and mortality rates, were collected for each state. The analysis phase compared the coded legal data with health outcomes to assess the impact of different SOP laws.

Results: States with the highest number of NPs (approximately 20,000) tended to have the most restrictive SOP laws, while states with the lowest NP populations (around 2,000) had full SOP laws. States with full SOP demonstrated better primary care physician (PCP) to population ratios, ranging from 89.1 to 101.1 per 100,000 residents. No clear trends emerged regarding mortality rates and NP SOP laws. However, states with restricted SOP had the shortest PCP wait times, while full SOP states had the longest wait times. 

Conclusion: Full SOP for NPs can increase primary care access but does not necessarily improve mortality rates. Larger states face challenges in regulating full SOP NPs, possibly explaining why they have higher restrictions. Traditionally restrictive states like California and Texas are now considering bills to grant full SOP to NPs. This shift suggests a growing recognition of NPs' potential increase primary care access, highlighting the ongoing evolution of healthcare policy as states seek to balance professional regulation with the need for expanded primary care access to overcome the physician shortage.

Addressing the U.S. Physician Shortage: A Legal Epidemiology Analysis of Nurse Practitioner Scope of Practice Laws and Their Impact on Primary Care Access

Background: Timely initiation of antiretroviral therapy (ART) for non-occupational post-exposure prophylaxis (nPEP) is crucial in preventing HIV infection and advancing efforts to end the HIV epidemic (EHE). nPEP must be administered within 72 hours of high-risk exposure, ideally within 24 hours. Pharmacies may play a role in increasing access to nPEP and facilitating referrals for additional care, such as PrEP. Recent legislation permits pharmacist-prescribed nPEP (PDP), though provider attitudes toward this change have not been studied.
Methods: A survey querying physicians and medical trainees (students and residents) was conducted in 2024 during an annual state medical association conference. The survey included 24 questions on nPEP knowledge and attitudes towards pharmacist-prescribed nPEP (PDP). The survey was administered in person using electronic tablets, with voluntary participation incentivized by a monetary reward. Statistical analysis was conducted using SAS (9.4 version) software, with differences in responses between physicians and trainees evaluated. P values <0.05 were considered statistically significant.
Results: Of 89 respondents (56% of attendees), 61 were physicians and 28 were trainees. Notably, 28% of licensed providers indicated that pharmacist-directed prescribing (PDP) should not be allowed in the State of Ohio, while no trainees expressed this same opposition (p=0.001). Trainees were more likely to view pharmacist prescribing as safe and appropriate ((p =0.0135, p=0.013). Urban-based providers were more supportive of pharmacist prescribing than their rural counterparts (p=0.0195).
Conclusion: Trainees showed little opposition to PDP, whereas physicians expressed concerns about safety and appropriateness. Addressing these concerns is essential for integrating pharmacists into the EHE strategy.

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