Impact of the USMLE Step 1 and COMLEX Level 1 transition to Pass/Fail on osteopathic medical student stress levels and board preparation

CONTEXT

The United States Medical Licensing Examination (USMLE) Step 1 and Comprehensive Osteopathic Medical Licensing Exam (COMLEX) Level 1 transitioned from a numeric scoring system to a Pass/Fail designation in 2022. This transition intended to decrease stress, improve medical student well-being, and encourage residency program directors to emphasize other aspects of residency applications. Pass/Fail score transitions in the undergraduate medical education curriculum have improved medical student psychological well-being and satisfaction; whether these same benefits translate to the board examination period is unknown.

OBJECTIVES

The objectives of this study are to assess the impact of USMLE Step 1 and COMLEX Level 1 grade scale transition on medical student stress, wellness, board preparation decisions, and future residency selection processes. Investigators hypothesized that students under the Pass/Fail designation would experience less stress during the intensive study period leading up to USMLE Step 1 and COMLEX Level 1 and devote more time to other aspects of their residency applications.

METHODS

To examine the impact on osteopathic medical student (OMS) stress and approach to board preparation, two surveys were administered to Rocky Vista University College of Osteopathic Medicine (RVU-COM) students before (Class of 2023) and after (Class of 2024) the transition to a Pass/Fail designation. All students within the RVU-COM Classes of 2023 and 2024 were invited to participate. The Cohen Perceived Stress Scale (PSS-10) was administered at the beginning of the focused board study period in May 2021 and 2022 to the Class of 2023 and 2024, respectively. The investigator-designed Licensing Exam Questionnaire (LEQ), meant to capture board preparation patterns, residency application perspectives, and wellness during examination preparation, was administered immediately after the board examination deadline in July 2021 and 2022 to the Class of 2023 and 2024, respectively. Statistical analysis included the use of independent t tests (numeric variables) and chi-square tests (categorical data). This project was considered exempt from full Institutional Review Board review.

RESULTS

Approximately one-third of the Class of 2023 (PSS-10: n=86; LEQ: n=93) and 2024 (PSS-10=89; LEQ: n=92) responded. No difference was detected in mean PSS-10 score, 20.14 (SD=7.3) compared to 19.92 (SD=6.56) for the Class of 2023 and 2024 (p=0.84), respectively. The Class of 2023 reported more weeks studying (mean 6.27 weeks, SD=0.79) vs. the Class of 2024 (mean 5.44 weeks, SD=0.007), p<0.001, more practice examinations taken X 2 (1, n=182)=13.75, p<0.001, and a greater proportion scheduled examinations after June 20 X 2 (1, n=182)=29.01, p<0.001. No difference existed in hours studying per day, sequence of Step 1/Level 1, time between examinations, money spent, or type of study resources utilized.

CONCLUSIONS

The transition of USMLE Step 1 and COMLEX Level 1 to a Pass/Fail designation did not reduce stress for OMSs at a single, multicampus COM. Respondents, however, altered board preparation practices in meaningful ways. As student behaviors and board-study patterns emerge, these insights must be connected to outcomes in the future.

Association Between Performance on COMLEX-USA and the American College of Osteopathic Family Physicians In-Service Examination

BACKGROUND

The primary goal of residency programs is to select and educate qualified candidates to become competent physicians. Program directors often use performance on licensure examinations to evaluate the ability of candidates during the resident application process. The American College of Osteopathic Family Physicians (ACOFP) administers an in-service examination (ISE) to residents annually. There are few prior studies of the relationship between the Comprehensive Osteopathic Medical Licensing Examination of the United States of America (COMLEX-USA) series and formative assessments of residents in training.

OBJECTIVE

We explored the relationship between performance on COMLEX-USA and the ACOFP in-service examination to offer support on the use of licensing examinations in resident selection.

METHODS

In 2016, performance data from the COMLEX-USA and the ISE were matched for 3 resident cohorts (2011-2013, inclusive; N = 1384). Correlations were calculated to examine the relationship between COMLEX-USA and ISE scores. Multiple linear regression models were used to determine if performance on COMLEX-USA significantly predicted third-year ISE (ISE-3) scores.

RESULTS

Findings indicated that correlations among performance on COMLEX-USA and ISE were statistically significant (all P < .001), and there was strong intercorrelation between COMLEX-USA Level 3 and ISE-1 performance (r = 0.57, P < .001). Performance on the COMLEX-USA Levels 1 and 2-Cognitive Examination significantly predicted performance on the ISE-3 (F(2,1381) = 228.8, P < .001).

CONCLUSIONS

The results support using COMLEX-USA as a part of resident selection in family medicine. Additionally, program directors may use performance on COMLEX-USA to predict success on the ISE-3.

Osteopathic Physicians on the Editorial Boards of Major Medical Journals Over the Past 30 Years

CONTEXT

With the recent merger of the American Osteopathic Association and the Accreditation Council for Graduate Medical Education, new standards may be established for scholarly activity criteria and designation for each specialty.

OBJECTIVE

To determine the percentage of osteopathic physicians on editorial boards in general and specialty medical journals and to compare the participation of osteopathic vs allopathic physicians and other health care researchers in editorial activities.

METHODS

The number of osteopathic and allopathic physicians and other health care professionals serving as editor in chief, associate editor, editorial board member, emeritus editor, or in other editorial positions was examined in 8 major medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine, Annals of Surgery, Annals of Emergency Medicine, Annals of Family Medicine, Obstetrics and Gynecology, and Pediatrics) published during the past 30 years.

RESULTS

The number of editorial board positions increased during the past 30 years, with Annals of Surgery adding the most positions (64). When compared with allopathic physicians in all fields of medicine, the number of osteopathic physicians serving on an editorial board of a medical journal was significantly less (P<.001). When all editorial positions were combined, osteopathic physicians occupied 0.15% of all positions.

CONCLUSION

A disparity exists between the numbers of osteopathic vs allopathic physicians in editorial positions in the core disciplines of medicine. Further investigation into the reasons why few osteopathic physicians serve in editorial roles is needed.

From "Doctor of Osteopathy" to "Doctor of Osteopathic Medicine": a title change in the push for equality

Nationally, the California merger created great solidarity among osteopathic members of state and national osteopathic associations. They rebuffed further efforts at amalgamation and championed the continuation of the DO degree. Even after the American Medical Association (AMA) opened its doors to DOs to join local and state medical associations as well as the AMA itself and gave its blessing to them entering allopathic residency programs and becoming MD board certified, the DOs stood fast for their independence. Yet some across the country wanted to become known as MDs. A few osteopathic physicians even went to federal court to claim-unsuccessfully-that state medical boards' refusal to license them or allow them to identify themselves as MDs violated their constitutional rights under the 1st and 14th Amendments. In the mid-1990s, the American Osteopathic Association (AOA) gave individual osteopathic medical colleges the option of indicating on their diplomas that the DO degree signified "Doctor of Osteopathic Medicine" rather than "Doctor of Osteopathy," a change that paralleled previous AOA policy changes regarding appropriate professional language. Nevertheless, some DOs and particularly a sizable number of osteopathic medical students continued to write of their desire for a change in the degree osteopathic medical colleges awarded. However, in July 2008 the AOA House of Delegates unanimously reaffirmed its commitment to continuing the traditional DO degree.

Osteopathic Continuous Certification: it's here--are you prepared?

The authors explain Osteopathic Continuous Certification (OCC) as mandated by the American Osteopathic Association Board of Trustees. Implemented on January 1, 2013, OCC is the process wherein osteopathic physicians certify their training and expertise in their chosen specialty and maintain the standard of excellence begun with the initial American Osteopathic Association certification. In contrast to one-time examinations, OCC is intended to be an ongoing, lifelong process for osteopathic physicians.

An international health elective in Haiti: a case for osteopathic medicine

As global health education becomes increasingly important, more physicians are participating in international health electives (IHEs). Haiti is a favorable site for an IHE because of its substantial health care needs and rich culture. Although both osteopathic and allopathic physicians can provide effective health care to Haitians, osteopathic physicians may be particularly well suited to serve in Haiti because of their training in osteopathic manipulative treatment (OMT). Because OMT's laying of the hands (high touch) is similar to the touch inherent to Haiti's traditional ethnomedical practices, osteopathic physicians' use of OMT can enhance trust among Haitians and increase Haitians' willingness to work with westernized medical practitioners. In addition, an IHE in a low-resource country such as Haiti can provide osteopathic physicians with a global outlook on medicine and a range of critical communication and clinical skills. The authors advocate for the development of an IHE in Haiti for osteopathic physicians.

Osteopathic graduate medical education 2013

The authors report updates on osteopathic graduate medical education training programs and positions for the 2011-2012 academic year. American Osteopathic Association Match trends and information on training slots are also examined.

AOA continuing medical education

The author provides an update on the current continuing medical education (CME) cycle, which began on January 1, 2013, and will end on December 31, 2015. The author also details the changes to the CME guide for osteopathic physicians, the requirements for Category 1 CME sponsors accredited by the American Osteopathic Association (AOA), and new online CME opportunities. Topic areas include recent changes in CME policies and the continuing challenges associated with awarding and recording CME credits for osteopathic physicians who hold specialty board certification. In addition, the article provides an update for osteopathic specialists and subspecialists in requesting AOA Category 1-A credit for American Medical Association Physician's Recognition Award Category 1 courses.

New colleges of osteopathic medicine: steps in achieving accreditation--an update

The American Osteopathic Association Commission on Osteopathic College Accreditation (AOA COCA) is recognized by the US Secretary of Education as the only accrediting agency for predoctoral osteopathic medical education. To maintain its recognition with the US Secretary of Education, AOA COCA is required to adhere to all federal laws and regulations associated with recognition of accrediting agencies. The authors discuss changes in the policies and procedures applicable to developing new colleges of osteopathic medicine (COMs) and discuss the COMs that have been granted Accreditation status since 2008. Also included is a review of AOA COCA-approved class sizes for accredited COMs.

Osteopathic postdoctoral training institutions and academic sponsorship

Since July 2012, all osteopathic graduate medical education programs approved by the American Osteopathic Association are academically sponsored by an Osteopathic Postdoctoral Training Institution (OPTI). The author reviews recent activities related to OPTI operations, including OPTI historical data and academic sponsorship changes, revisions to the OPTI Accreditation Handbook, and the 2012 OPTI Workshop. The author also summarizes the new OPTI Mission and Vision Statements, examines OPTI governance, and cites common commendations and deficiencies for reviews completed from 2008 to 2012.

AOA specialty board certification

The authors details information related to the 2012 certification processing activity of the Bureau of Osteopathic Specialists, which oversees the work of the 18 specialty certifying boards of the American Osteopathic Association.

Osteopathic physicians and international medical graduates in the rural primary care physician workforce

BACKGROUND AND OBJECTIVES

Primary care physician (PCP) shortages are a longstanding problem in the rural United States. This study describes the 2005 supply of two important components of the rural PCP workforce: rural osteopathic (DO) and international medical graduate (IMG) PCPs.

METHODS

American Medical Association (AMA) and American Osteopathic Association (AOA) 2005 Masterfiles were combined to identify clinically active, non-resident, non-federal physicians aged 70 or younger. Rural-Urban Commuting Area codes were used to categorize practice locations as urban, large rural, small rural, or isolated small rural. National- and state-level analyses were performed. PCPs included family physicians, general internists, and general pediatricians.

RESULTS

DOs comprised 4.9% and IMGs 22.2% of the total clinically active workforce. However, they contributed 10.4% and 19.3%, respectively, to the rural PCP workforce, although their relative representation varied geographically. DO PCPs were more likely than allopathic PCPs to practice in rural places (20.5% versus 14.9%, respectively). IMG PCPs were more likely than other PCPs to practice in rural persistent poverty locations (12.4% versus 9.1%). The proportion of rural PCP workforce represented by DOs increased with increasing rurality and that of IMGs decreased.

CONCLUSIONS

DO and IMG PCPs constitute a vital portion of the rural health care workforce. Their ongoing participation is necessary in addressing existing rural PCP shortages and handling the influx of newly insured residents as the Patient Protection and Affordable Care Act (ACA) comes into effect. The impact on rural DO and IMG PCP supply of ACA measures intended to increase their numbers remains to be seen.

Trainer-to-student ratios for teaching psychomotor skills in health care fields, as applied to osteopathic manipulative medicine

The hallmark of osteopathic medical education is the inclusion of hands-on instruction in osteopathic manipulative medicine (OMM), which includes palpatory diagnosis and osteopathic manipulative treatment (OMT). This OMM training typically involves a primary instructor presenting theory and techniques with step-by-step demonstrations to a large group of first- and second-year osteopathic medical students. Additional instructors, referred to as table trainers, assist the primary instructor by supervising the students as they practice the presented techniques. To the authors' knowledge, there is no currently accepted standard for a table trainer-to-student ratio in OMM skills laboratories within osteopathic medical schools in the United States. However, through a Google Web search and PubMed literature review, the authors identified published trainer-to-student ratios used in other health care skills training curricula. Psychomotor skills training courses in health care fields typically have a table trainer-to-student ratio of 1 trainer to 8 or fewer students. On the basis of these findings and psychomotor skills learning theory, the authors conclude that this ratio is likely sufficient for OMM skills training.

Prediction of Osteopathic Medical School Performance on the basis of MCAT score, GPA, sex, undergraduate major, and undergraduate institution

CONTEXT

The relationships of students' preadmission academic variables, sex, undergraduate major, and undergraduate institution to academic performance in medical school have not been thoroughly examined.

OBJECTIVES

To determine the ability of students' preadmission academic variables to predict osteopathic medical school performance and whether students' sex, undergraduate major, or undergraduate institution influence osteopathic medical school performance.

METHODS

The study followed students who graduated from New York College of Osteopathic Medicine of New York Institute of Technology in Old Westbury between 2003 and 2006. Student preadmission data were Medical College Admission Test (MCAT) scores, undergraduate grade point averages (GPAs), sex, undergraduate major, and undergraduate institutional selectivity. Medical school performance variables were GPAs, clinical performance (ie, clinical subject examinations and clerkship evaluations), and scores on the Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) Level 1 and Level 2-Clinical Evaluation (CE). Data were analyzed with Pearson product moment correlation coefficients and multivariate linear regression analyses. Differences between student groups were compared with the independent-samples, 2-tailed t test.

RESULTS

A total of 737 students were included. All preadmission academic variables, except nonscience undergraduate GPA, were statistically significant predictors of performance on COMLEX-USA Level 1, and all preadmission academic variables were statistically significant predictors of performance on COMLEX-USA Level 2-CE. The MCAT score for biological sciences had the highest correlation among all variables with COMLEX-USA Level 1 performance (Pearson r=0.304; P<.001) and Level 2-CE performance (Pearson r=0.272; P<.001). All preadmission variables were moderately correlated with the mean clinical subject examination scores. The mean clerkship evaluation score was moderately correlated with mean clinical examination results (Pearson r=0.267; P<.001) and COMLEX-USA Level 2-CE performance (Pearson r=0.301; P<.001). Clinical subject examination scores were highly correlated with COMLEX-USA Level 2-CE scores (Pearson r=0.817; P<.001). No statistically significant difference in medical school performance was found between students with science and nonscience undergraduate majors, nor was undergraduate institutional selectivity a factor influencing performance.

CONCLUSION

Students' preadmission academic variables were predictive of osteopathic medical school performance, including GPAs, clinical performance, and COMLEX-USA Level 1 and Level 2-CE results. Clinical performance was predictive of COMLEX-USA Level 2-CE performance.

Osteopathic distinctiveness in osteopathic predoctoral education and its effect on osteopathic graduate medical education

The number of colleges of osteopathic medicine (COMs), osteopathic medical students, and osteopathic physicians in practice has been consistently growing since the 1960s. In recent years, the growth of the profession has been exponential. Despite this growth, graduates of COMs are increasingly choosing allopathic residencies. The authors believe that this trend may stem from a lack of focus on osteopathic principles and practice in COMs, as well as geographic and specialty limitations of available osteopathic residency positions. The present article will briefly examine the history of AOA accreditation and the current accreditation process and the current state of osteopathic predoctoral education and postdoctoral training. The authors call on osteopathic physicians to help bring osteopathic distinctiveness to osteopathic predoctoral education by mentoring and volunteering at COMs. In addition, the authors urge the osteopathic profession to increase the number of osteopathic residencies to account for the number of and distribution of osteopathic medical school graduates.

Pass/fail patterns of candidates who failed COMLEX-USA level 2-PE because of misrepresentation of clinical findings on postencounter notes

CONTEXT

In 2007, The National Board of Osteopathic Medical Examiners (NBOME) instituted a policy to address the accuracy and integrity of postencounter written documentation recorded during the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation (COMLEX-USA Level 2-PE). This policy was instituted not only to protect the integrity of the examination, but also to highlight that overdocumentation of clinical findings not obtained during patient encounters may jeopardize patient safety.

OBJECTIVE

To investigate overall and domain pass/fail patterns of candidates who misrepresented clinical findings with regard to past and subsequent performance on COMLEX-USA Level 2-PE. Specifically, to investigate what percentage of candidates failed because of misrepresentation on first attempts and how they performed on subsequent administrations, as well as the previous performance patterns of candidates who failed because of misrepresentation on examination retakes.

METHODS

Historical records from NBOME's COMLEX-USA Level 2-PE database (testing cycles 2007-2008, 2008-2009, and 2009-2010) were used to analyze overall and domain pass/fail patterns of candidates who failed at least once because of misrepresentation of clinical findings.

RESULTS

Of the 24 candidates who failed because of misrepresentation of postencounter (SOAP) notes, 20 candidates (83%) were first-time examinees. Four candidates (17%) were repeating the examination, 2 of whom were making a third attempt to pass. Among these 20 candidates who failed because of misrepresentation of clinical findings on their first attempt, 19 passed on their next attempt. At the time of study analysis, all but 2 candidates eventually passed the examination in subsequent attempts.

CONCLUSION

Among candidates found to have misrepresented clinical findings on postencounter written documentation on COMLEX-USA Level 2-PE, no pattern existed between their past or subsequent performance with regard to overall or domain pass/fail results. The vast majority of these candidates passed the examination on subsequent administrations, and none failed twice because of misrepresentation. Consequences of misrepresentation of clinical findings on COMLEX-USA Level 2-PE are severe and may serve to both raise awareness and prevent these types of errors in the future.

Finding a faster route to practice: from medical student to board certified physician

An examination of two types of educational tracks used by medical students seeking a faster route to practice: 1) "3+3" programs that combined the final year of medical school with the first year of a primary care residency, and 2) graduating from medical school after only three years. The "3+3" programs were discontinued despite reports indicating their success. Three year medical school options are still available at a handful of medical schools. Finally, the paper will explore why and how medical schools might wish to enact a three year curricular option.

American Osteopathic Association specialty board certification

Specialty board certification is an important tool in recognizing physicians who take extra measures to establish their skills in any number of specialty areas. The American Osteopathic Association Bureau of Osteopathic Specialists, which oversees the 18 specialty certifying boards, continues to amend existing policies and implement new policies to improve the certification process. Among these policies, the authors describe new collaboration efforts, the development of the osteopathic continuous certification process, and revisions to board eligibility. An update on AOA certification awards, including certificates of added qualifications, is also provided.

Evaluation of an interactive, case-based review session in teaching medical microbiology

BACKGROUND

Oklahoma State University-Center for Health Sciences (OSU-CHS) has replaced its microbiology wet laboratory with a variety of tutorials including a case-based interactive session called Microbial Jeopardy!. The question remains whether the time spent by students and faculty in the interactive case-based tutorial is worthwhile? This study was designed to address this question by analyzing both student performance data and assessing students' perceptions regarding the tutorial.

METHODS

Both quantitative and qualitative data were used in the current study. Part One of the study involved assessing student performance using archival records of seven case-based exam questions used in the 2004, 2005, 2006, and 2007 OSU-CHS Medical Microbiology course. Two sample t-tests for proportions were used to test for significant differences related to tutorial usage. Part Two used both quantitative and qualitative means to assess student's perceptions of the Microbial Jeopardy! session. First, a retrospective survey was administered to students who were enrolled in Medical Microbiology in 2006 or 2007. Second, responses to open-ended items from the 2008 course evaluations were reviewed for comments regarding the Microbial Jeopardy! session.

RESULTS

Both student performance and student perception data support continued use of the tutorials. Quantitative and qualitative data converge to suggest that students like and learn from the interactive, case-based session.

CONCLUSION

The case-based tutorial appears to improve student performance on case-based exam questions. Additionally, students perceived the tutorial as helpful in preparing for exam questions and reviewing the course material. The time commitment for use of the case-based tutorial appears to be justified.

OPTImizing osteopathic postdoctoral training institutions

Since 1999, all postdoctoral training programs approved by the American Osteopathic Association (AOA) have been required to be part of an Osteopathic Postdoctoral Training Institution (OPTI) consortium. The AOA is improving OPTI operations by revising the OPTI Annual Report, by providing provisional status for new OPTIs, and by using the Residency Management Suite software program (New Innovations Inc, Uniontown, Ohio). The revised OPTI Annual Report is being modeled after the OPTI Standards Inspectors Worksheet (ie, Standards Crosswalk). Onsite inspections using the new scoring tool in 2008 highlighted OPTI best practices by demonstrating that OPTIs received commendations for faculty and curriculum development. Inspections have also shown that OPTIs with accreditation awards of 4 or 5 years are more likely than other OPTIs to be composed of 4- or 5-year postdoctoral training programs.