Where are the Black men in osteopathic medical schools?

Over the past decade, the American Association of Colleges of Osteopathic Medicine (AACOM) and the Association of American Medical Colleges (AAMC) have emphasized the need to enhance diversity within medical education. Despite concerted efforts, the representation of underrepresented populations in medicine (URiM), particularly Black men, remains alarmingly low. This commentary delves into the persisting challenges and potential solutions surrounding the lack of diversity of Black men in osteopathic schools. Black men, in particular, continue to be significantly underrepresented in osteopathic medical schools across the United States. Factors contributing to this disparity include limited access to resources, pervasive negative stereotypes, and biases within the medical community. Addressing these challenges necessitates multifaceted interventions such as mentorship programs, pipeline initiatives, and implicit bias training to enhance the recruitment and support for URiM applicants, particularly Black men. Institutions like Touro College of Osteopathic Medicine and A.T. Still University have underscored the importance of tailoring programs in fostering a sense of belonging and academic success among Black men aspiring to be osteopathic physicians. The creation of a supportive environment for Black men in osteopathic medical schools is not only crucial for promoting diversity but also crucial for improving patient health outcomes, because research consistently depicts enhanced patient outcomes and experiences with diverse healthcare teams. However, despite progress in some areas, Black men continue to face systemic barriers and biases that hinder the pursuit of a career in osteopathic medicine. Thus, increasing the representation of Black men in osteopathic medical schools requires a concerted effort from all stakeholders, including medical institutions, policymakers, and the broader medical community. By implementing targeted interventions, fostering a sense of belonging, and addressing systemic barriers, the medical community can work toward a more equitable and inclusive future in healthcare. Ultimately, promoting diversity is not only a matter of fairness but also essential for ensuring the delivery of high-quality, culturally competent care to all patients.

The Fragility of Statistical Findings in the Femoral Neck Fracture Literature: A Systematic Review of Randomized Controlled Trials

OBJECTIVES

Randomized controlled trials (RCTs) in the femoral neck fracture literature frequently report p-values for outcomes which have substantial implications in guiding surgical management. This study utilized the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to assess the statistical stability of outcomes reported in RCTs evaluating the management and treatment of femoral neck fractures.

METHODS

Data Sources: Pubmed, Emabse, and MEDLINE were queried for RCTs (January 1, 2010 to February 28th, 2023) that evaluated surgical management/treatment of femoral neck fractures. Study Selection: RCTs with two treatment arms reporting categorical dichotomous outcomes were included. Non-RCT studies, RCTs with greater than 2 treatment arms, and RCTs without a femoral neck fracture cohort were excluded.Data Extraction and Synthesis: The FI and rFI were calculated as the number of outcome event reversals required to alter statistical significance for significant (p<0.05) and non-significant (p≥0.05) outcomes, respectively. The FQ was calculated by dividing the FI by the sample size for the study.

RESULTS

985 articles were screened with 71 studies included for analysis. The median FI across a total of 197 outcomes was 4 (IQR 2-5) with an associated FQ of 0.033 (IQR 0.017-0.060). 47 outcomes were statistically significant with a median FI of 2 (IQR 1-4) and associated FQ of 0.02 (IQR 0.014-0.043). 150 outcomes were statistically non-significant with a median rFI of 4 (IQR 3-5) and associated FQ of 0.037 (IQR 0.019-0.065).

CONCLUSION

Statistical findings in femoral neck fracture RCTs are fragile with reversal of a median 4 outcomes altering significance of study findings. The authors thus recommend standardized reporting of p-values with FI and FQ metrics to aid in interpreting the robustness of outcomes in femoral neck fracture RCTs.

LEVEL OF EVIDENCE

Level I. See Instructions for Authors for a complete description of levels of evidence.

The Fragility of Statistical Findings in the Reverse Total Shoulder Arthroplasty Literature: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has seen increasing utilization as an effective intervention for a wide variety of shoulder pathologies. The scope and indications for growth are often driven by findings from randomized controlled trials (RCTs) guiding surgical decision-making for RTSA. In this study, we utilized the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to assess the robustness of outcomes reported in RCTs in the RTSA literature.

METHODS

PubMed, Embase, and MEDLINE were queried for RCTs (Jan. 1, 2010-Mar. 31, 2023) in the RTSA literature reporting dichotomous outcomes. The FI and rFI were defined as the number of outcome reversals required to alter statistical significance for significant and non-significant outcomes, respectively. The FQ was determined by dividing the FI by the sample size of each study. Subgroup analysis was performed based on outcome category.

RESULTS

176 RCTs were screened with 18 studies included. The median FI across 59 total outcomes was 4 (IQR 3-5) with an associated FQ of 0.051 (IQR 0.029-0.065). 13 outcomes were statistically significant with a median FI of 3 (IQR 1-4) and FQ of 0.033 (IQR 0.012-0.066). 46 outcomes were non-significant with a median rFI of 4 (IQR 3-5) and FQ of 0.055 (IQR 0.032-0.065). The most fragile outcome category was revision/reoperations with a median FI of 2.50 (IQR 1.00-3.25), followed by clinical score/outcome (median FI 3.00), complications (median FI 4.00), "other" (median FI 4.00), and radiographic findings (median FI 5.00). Notably, the number of patients lost to follow-up was greater than or equal to the FI for 59% of outcomes.

CONCLUSION

The statistical findings in RTSA RCTs are fragile and should be interpreted with caution. Reversal of only a few outcomes, or maintaining postoperative follow-up, may be sufficient to alter significance of study findings. We recommend standardized reporting of P values with FI and FQ metrics to allow clinicians to effectively assess the robustness of study findings.

The Fragility of Statistical Findings in Distal Biceps Tendon Repairs: a Systematic Review of Randomized Controlled Trials

BACKGROUND

The purpose of this present study was to perform a fragility analysis to assess the robustness of randomized controlled trials (RCTs) evaluating the distal biceps tendon repairs. We hypothesize that the dichotomous outcomes will be statistically fragile and higher fragility will exist among statistically significant outcomes comparable to other orthopedic specialties.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), randomized controlled trials from 4 orthopedic journals indexed on PubMed from 2000 to 2022 reporting dichotomous measures relating to distal biceps tendon repairs were included. The fragility index (FI) of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The fragility quotient (FQ) was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ.

RESULTS

Of the 1038 articles screened, seven RCTs containing 24 dichotomous outcomes were included for analysis. The fragility index and fragility quotient of all outcomes was 6.5 (IQR 4-9) and 0.077 (IQR 0.031-0.123), respectively. However, statistically significant outcomes had a fragility index and fragility quotient of 2 (IQR 2-7) and 0.036 (IQR 0.025-0.091), respectively. The average number of patients lost to follow-up was 2.7 patients with 28.6% of the included studies reporting loss to follow-up (LTF) greater than or equal to 6.5.

CONCLUSIONS

The literature surrounding distal biceps tendon repair may not be as stable as previously thought and presents a similar fragility index to other orthopedic subspecialties. We therefore recommend triple reporting the P value, fragility index and fragility quotient to aid in the interpretation of clinical findings reported in biceps tendon repair literature.

The Statistical Fragility of Orbital Fractures: A Systematic Review of Randomized Controlled Trials

BACKGROUND

The P value has often been used as a tool to determine the statistical significance and evaluate the statistical robustness of study findings in orthopedic literature. The purpose of this study is to apply both the fragility index (FI) and the fragility quotient (FQ) to evaluate the degree of statistical fragility in orbital fracture literature. We hypothesized that the dichotomous outcomes within the orbital fracture literature will be vulnerable to a small number of outcome event reversals and will be statistically fragile.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors identified all dichotomous data for randomized controlled trials (RCTs) in orbital fracture literature and performed a PubMed search from 2000 to 2022. The FI of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each FI by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ.

RESULTS

Of the 3,329 studies screened, 28 met the criteria with 10 RCTs evaluating orbital fractures included for analysis. A total of 58 outcome events with 22 significant (P < .05) outcomes and 36 nonsignificant (P ≥ .05) outcomes were identified. The overall FI and FQ for all 58 outcomes was 5 (IQR: 4 to 5) and 0.140 (IQR: 0.075 to 0.250), respectively. Fragility analysis of statistical significant outcomes and nonsignificant outcomes had an FI of 3.5 with no IQR and 5 (IQR 4-5), respectively. All of the studies reported a loss to follow-up data, where 20% (2) was greater than the overall FI of 5.

CONCLUSION

The orbital fracture literature provides treatment guidance by relying on statistical significant results from RCTs. However, the RCTs in the orbital fracture peer-reviewed literature may not be statistically stable as previously thought. The sole reliance of the P value may depict misleading results. Thus, we recommend standardizing the reporting of the P value, FI, and FQ in the orbital fracture literature to aid readers in reliably drawing conclusions based on fragility outcome measures impacting clinical decision-making.