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Impostorism is prevalent in medical students and negatively impacts wellness, contributing to stress and burnout. Perceived competence is noted as one attribute underlying impostorism. A curricular change that resulted in improved United States Medical Licensing Examination (USMLE) Step 1 scores and student self-perceptions of preparedness for clinical training was used as a natural experiment to assess the effects higher competence/preparedness, based on an objective indicator and self-perceptions, on impostorism, stress, and burnout during early clinical training. Third-year medical students in the last class of the old “Legacy” curriculum and the first class of the revised “ACE” curriculum completed a voluntary, anonymous survey that included the Clance Impostor Phenomenon Scale, the Perceived Stress Scale, and the abbreviated Maslach Burnout Assessment. USLME Step 1 scores and data on students’ self-perception of their preparedness for clinics were collected as part of routine curricular monitoring. Both groups of students had highly similar entering demographics. Compared to Legacy students, ACE students had higher USMLE Step 1 scores (p < 0.001) and perceived themselves to be better prepared for clinical clerkships (p < 0.001). Stress scores were 15% lower in ACE students (p < 0.05). However, impostor scores were nearly identical between these groups and the proportions of students endorsing burnout were not different. This suggests that impostorism and burnout during the transition to clinical training are not attenuated by improved competence and are not directly related to stress.

OBJECTIVE: The objective of this study was to describe the implementation of Clinical Anatomy Mentorship Program (CAMP), a novel near-peer surgical anatomy teaching program, into the KU School of Medicine (KUSOM) Surgery Clerkship curriculum. DESIGN: Prospective qualitative and quantitative study. SETTING: Single institution, tertiary care hospital. PARTICIPANTS: All M3s at KUSOM on their surgery clerkship were eligible for inclusion for the learner cohort, n = 106. A group of M4s self-identified as CAMP mentors were eligible for inclusion for the teacher cohort, n = 40. RESULTS: M3s have statistically significant higher self-efficacy (p < 0.001) scores after participating in CAMP. Among open-ended comments written by M3s, significant themes highlighted that CAMP taught them a much-needed refresher on anatomy, gave them an introduction to surgical anatomy, and felt peer-to-peer teaching created a safe environment to ask questions. M4 mentors reported statistically significant (p < 0.001) increases in self-efficacy and confidence in teaching skills after teaching CAMP sessions. Among open-ended comments written by M4 mentors, significant themes highlighted that CAMP helped them develop their teaching skills and confidence in the operating room. CONCLUSIONS: In line with current medical education practices, KUSOM has significantly decreased anatomy in the curriculum. We responded to this shift by implementing CAMP, designed to address specific medical student needs for a surgically oriented anatomy instruction. CAMP has been effective at addressing student concerns about anatomy knowledge gaps. CAMP has enhanced self-efficacy, anatomy knowledge, and operating room exposure in M3s, and self-efficacy, teaching skills, surgical anatomy knowledge, and surgical confidence in M4s.

The objective of this study was to identify specific olfactory phenotypes-patterns of olfactory performance-across distinct cohorts with or without olfactory dysfunction (OD). Adult patients underwent testing via a novel olfactory testing methodology in 1 of 4 groups based on health status: sinonasal inflammatory condition (chronic rhinosinusitis or allergic rhinitis), ≥4 weeks of self-reported OD after resolved COVID-19 infection, Alzheimer's disease, and healthy control. Participants' scores for each scent were normalized on a scale of 0 to 1 relative to their worst and best scores. Agglomerative hierarchal cluster analysis was performed on normalized data for the COVID-19 and sinonasal cohorts. Resulting clusters from the penultimate merger revealed a sensitivity of 81% and specificity of 63% for the detection of patients with COVID-19. These results support that there are olfactory phenotypes that may discriminate COVID-19 OD from sinonasal inflammatory disease. These phenotypes will likely become increasingly leveraged in the workup and treatment of patients with OD.

OBJECTIVE. Consumer wearables, such as the Apple Watch or Fitbit devices, have become increasingly commonplace over the past decade. The application of these devices to health care remains an area of significant yet ill-defined promise. This review aims to identify the potential role of consumer wearables for the monitoring of otolaryngology patients. DATA SOURCES. PubMed. REVIEW METHODS. A PubMed search was conducted to identify the use of consumer wearables for the assessment of clinical outcomes relevant to otolaryngology. Articles were included if they described the use of wearables that were designed for continuous wear and were available for consumer purchase in the United States. Articles meeting inclusion criteria were synthesized into a final narrative review. CONCLUSIONS. In the perioperative setting, consumer wearables could facilitate prehabilitation before major surgery and prediction of clinical outcomes. The use of consumer wearables in the inpatient setting could allow for early recognition of parameters suggestive of poor or declining health. The real-time feedback provided by these devices in the remote setting could be incorporated into behavioral interventions to promote patients’ engagement with healthy behaviors. Various concerns surrounding the privacy, ownership, and validity of wearable-derived data must be addressed before their widespread adoption in health care. IMPLICATIONS FOR PRACTICE. Understanding how to leverage the wealth of biometric data collected by consumer wearables to improve health outcomes will become a high-impact area of research and clinical care. Well-designed comparative studies that elucidate the value and clinical applicability of these data are needed.

The term work-life balance may cause physicians to feel inadequate in pursuing a reality in which work and life each have equal importance. Furthermore, the term implies competition between these 2 realms. Instead, work-life integration is a more constructive and realistic term. Achieving harmonious integration requires self-reflection on the current state, goals, and resources and strategies needed to achieve and maintain such a state. Prioritizing aspects of both, and aligning them with individual requirements, while incorporating consistent and intentional investment of time and efforts in both professional and personal arenas is crucial to cultivate and sustain longitudinal well-being.

BackgroundDysfunction in the olfactory, auditory, and vestibular systems are commonly seen in aging and are associated with dementia. The impact of sensory loss(es) on cognition is not well understood. Our aim was to assess the relationships between performance on objective multisensory testing and quantify the impact of dysfunction on cognition.MethodsPatients presenting with subjective hearing loss presenting to a tertiary care otologic/audiologic clinic were identified and underwent multisensory testing using the Affordable, Rapid Olfactory Measurement Array (AROMA), pure tone audiometric evaluations, and the Timed “Up and Go” test. Cognitive impairment (CI) was assessed via the Montreal Cognitive Assessment (MoCA) was also administered.Key Results180 patients were enrolled. Thirty one percentage (n = 57) screened positive for cognitive impairment. When evaluating single sensory impairments, we found that olfactory dysfunction, gait impairment, and sensorineural hearing loss were all statistically significantly (p < 0.05) associated with a higher risk of cognitive impairment (ORs 3.89, 3.49, and 2.78, respectively) for CI. Multisensory impairment was significantly associated with cognitive impairment. Subjects with dysfunction in all domains were at the highest risk for cognitive impairment (OR 15.7, p < 0.001) vs. those with impairment in 2 domains (OR 5.32, p < 0.001).ConclusionDysfunction of the olfactory, auditory, and vestibular systems is associated with a significantly increased risk of CI. The dramatically increased risk of CI with multisensory dysfunction in all three systems indicated that MSD may synergistically contribute to CI.

Introduction: Understanding suburban, Kansas parental attitudes and adherence of recommended childhood vaccination schedules adopts a new level of importance in the era of the SARS-CoV-2019 (COVID-19) pandemic. With hopes for release of a safe and effective COVID-19 vaccine underway, understanding parental perception of vaccines is important to design successful vaccination interventions. Methods: A web-based, cross-sectional survey was administered to approximately 900 parents in Johnson County, Kansas during the summer of 2020. Pearson chi square and Mann-Whitney U tests were utilized to assess the attitudes of Kansas parents towards a potential addition of the influenza vaccine to the required list for K-12 students and furthermore, their general perception of vaccinations, and the impact of COVID-19 on those beliefs. Results: A total of 179 parents responded. Fifty-one percent (n = 92) were in favor of adding the influenza vaccine to the mandatory list (Pro-Addition). Anti-Addition parents had significantly higher levels of distrust (2.1, p < 0.001) and were significantly more concerned about vaccine adverse effects. When presented with a hypothetical situation in which a "safe and effective" COVID-19 vaccine was available, 24% of Anti-Addition parents indicated they would receive the vaccine or obtain it for their children (21 people, p < 0.001). Conclusions: Kansas suburban parents were split on their attitudes towards the addition of the influenza vaccine to the required list for children and the effects of the pandemic. Follow-up qualitative studies of Anti-Addition parents are critical for successful vaccine distribution and coverage in the communities.

Background: Olfactory dysfunction (OD) is an early symptom of Alzheimer’s disease (AD). However, olfactory testing is not commonly performed to test OD in the setting of AD. Objective: This work investigates objective OD as a non-invasive biomarker for accurately classifying subjects as cognitively unimpaired (CU), mild cognitive impairment (MCI), and AD. Methods: Patients with MCI (n = 24) and AD (n = 24), and CU (n = 33) controls completed two objective tests of olfaction (Affordable, Rapid, Olfactory Measurement Array –AROMA; Sniffin’ Sticks Screening 12 Test –SST12). Demographic and subjective sinonasal and olfaction symptom information was also obtained. Analyses utilized traditional statistics and machine learning to determine olfactory variables, and combinations of variables, of importance for differentiating normal and disease states. Results: Inability to correctly identify a scent after detection was a hallmark of MCI/AD. AROMA was superior to SST12 for differentiating MCI from AD. Performance on the clove scent was significantly different between all three groups. AROMA regression modeling yielded six scents with AUC of the ROC of 0.890 (p

Background Ambulatory surgery presents unique challenges regarding adequate pain management and education. Studies have documented issues with transfer of information and patient comfort. Our objective was to explore perioperative nurses’ perspectives of current practices and challenges with pain management and education. Materials and methods We used a qualitative descriptive design and conducted four focus group interviews, with 24 total participants from two perioperative areas of an academic medical center, using a standardized script. Using qualitative analysis software, two investigators reviewed the data and coded major themes and subthemes. The consolidated criteria for reporting qualitative studies guidelines were followed for reporting the data. Results We identified four major themes impacting current perioperative pain management and education practices: communication among the perioperative care team, sources of nurses’ frustrations in the perioperative setting, patient expectations for pain, and nurse-driven pain management and education. Nurses highlighted their work became easier with adequate information transfer and trust from physicians. Frustrations stemmed from surgeon, system, and patient factors. Nurses often use their clinical experience and judgment in managing patients throughout the perioperative period. Furthermore, nurses felt patients have limited pain education and stressed education throughout the surgical care pathway could improve overall care. Conclusions Perioperative pain management, assessment, and education practices are inconsistent, incomplete, and sources of frustrations according to participants. Participant experiences highlight the need for improved and standardized models. Patient pain education should use a multidisciplinary approach, beginning at the point of surgery scheduling and continuing through postoperative follow-up.

Objective: Scholastic activity through research involvement is a fundamental aspect of a physician’s training and may have a significant influence on future academic success. Here, we explore publication rates before, during, and after otolaryngology residency training and whether publication efforts correlate with future academic achievement. Methods: This cross-sectional analysis included a random sample of 50 otolaryngology residency programs. From these programs, we assembled a list of residents graduating from the years in 2013, 2014, and 2015. Using SCOPUS, PubMed, and Google Scholar, we compiled the publications for each graduate, and data were extracted in an independent, double-blinded fashion. Results: We included 32 otolaryngology residency programs representing 249 residents in this analysis. Graduates published a mean of 1.3 (SD = 2.7) articles before residency, 3.5 (SD = 4.3) during residency, and 5.3 (SD = 9.3) after residency. Residents who pursued a fellowship had more total publications ( t247 = −6.1, P 247 = −5.4, P 247 = −8.2, P 247 = −7.9, P Conclusion: Research productivity correlated with a number of characteristics such as future fellowship training, the pursuit of an academic career, and overall h-index in this study.

Objective Gender differences in personality have long been a subject of interest. This study assessed personality traits within female and male residents and faculty and evaluated for meaningful differences between the groups. Methods A series of web-based, commercially available, self-administered five factor-based personality assessments were given to otolaryngology residents and faculty at nine academic training programs. The psychometrically validated assessments evaluate innate personality 1) strengths, 2) challenges, and 3) motivators/values. Differences between groups were evaluated using the Mann-Whitney U test. A standardized measure of effect size, Cohen’s d, was calculated to indicate the magnitude of gender differences. Subset analysis was done to examine differences between female and male residents and female and male faculty. Results Seventy-eight faculty (42.6%) and 104 residents (70.3%), responded, which included 63 female (34.6%) participants. Significant differences between females and males overall were found across four traits (mischievous, imaginative, altruistic, and commercial) out of twenty-eight (4/28; 14.3%). Subset analysis of residents revealed two statistically significant differences related to motivators/values (increased altruism in females and increased commercial in males). Faculty exhibited a statistically significant difference in one stress tendency (increased imaginative in males). When examining the seven total traits that exhibited a statistically significant difference between any of the groups (7/84; 8.3%), four were considered a small difference and three a moderate difference. Conclusion When personality trait differences were identified in both otolaryngology resident and faculty populations based on gender, they were relatively small. Overall, females and males in otolaryngology exhibit significant overlap in the distribution of their personality traits. Therefore, personality-based initiatives should focus on the individual, rather than perceived gender “norms.”

Background Post-viral olfactory dysfunction is a common cause of both short- and long-term smell alteration. The coronavirus pandemic further highlights the importance of post-viral olfactory dysfunction. Currently, a comprehensive review of the neural mechanism underpinning post-viral olfactory dysfunction is lacking. Objectives To synthesize the existing primary literature related to olfactory dysfunction secondary to viral infection, detail the underlying pathophysiological mechanisms, highlight relevance for the current COVID-19 pandemic, and identify high impact areas of future research. Methods PubMed and Embase were searched to identify studies reporting primary scientific data on post-viral olfactory dysfunction. Results were supplemented by manual searches. Studies were categorized into animal and human studies for final analysis and summary. Results A total of 38 animal studies and 7 human studies met inclusion criteria and were analyzed. There was significant variability in study design, experimental model, and outcome measured. Viral effects on the olfactory system varies significantly based on viral substrain but generally include damage or alteration in components of the olfactory epithelium and/or the olfactory bulb. Conclusions The mechanism of post-viral olfactory dysfunction is highly complex, virus-dependent, and involves a combination of insults at multiple levels of the olfactory pathway. This will have important implications for future diagnostic and therapeutic developments for patients infected with COVID-19.

Objectives: (1) To investigate the state of diversity and inclusion initiatives in otolaryngology–head and neck surgery (OHNS) as compared to general surgery and (2) assess their effects on female representation in these programs. Methods: The websites of OHNS residency programs, general surgery residency programs, and their associated academic medical institutions were indexed for content related to diversity and inclusion (D&I) initiatives. Gender data were gathered and used as a proxy for identity diversity. Results: All programs surveyed (N = 198) have D&I programs at the institutional level and have an office of D&I (or equivalent program). However, only 18% of general surgery programs and 19% of otolaryngology programs have additional department-level D&I initiatives. There was an increase in the proportion of female residents across all residency programs if the program mentioned D&I on their website (44% vs 38%, P = .004) and if the program reported a D&I initiative (45% vs 38%, P < .001). Conclusion: Despite the ACGME’s recent emphasis on the importance of recruiting and retaining a diverse physician workforce, the minority of otolaryngology residency programs advertise any concerted, department-level efforts toward increasing D&I at their residency program. General surgery programs have a significantly higher proportion of female department chairs and higher mean proportion of female residents when compared to OHNS. Programs that mention the diversity of their residents or faculty on the program website and programs with their own D&I initiatives have a higher mean proportion of female residents.

Objectives This study examined the incidence and severity of impostorism in third-year medical students as they transitioned from the preclinical to clinical phases of training. Methods A cross-sectional study was conducted in third-year medical students (N=215). Respondents completed a voluntary, anonymous, 60-item survey that included the Clance Impostor Phenomenon Scale and the Perceived Stress Scale. Student’s-t, Mann-Whitney, and Chi-Square tests and Pearson correlation were used to determine differences between subgroups of students and relationships between instruments scores and demographic parameters. Results Fifty-nine percent of students responded with N=112 (59% female) completing at least one instrument. The mean impostor score was 63.0 ± 14.6 (moderate-to-frequent impostor feelings) and was 9% higher in females (U=1181, p = .046). Perceived Stress scores for females were 17% higher than males (t(109)=2.87, p=.005). Females had lower United States Medical Licensing Examination (USMLE) Step 1 scores (t(107)= 3.06, p=.003). Impostor and perceived stress scores were correlated for males (r(46)=.47, p=.002) and females (r(64)=.54,p

Introduction Impostorism, feelings of distrust in one’s abilities and accomplishments despite evidence to the contrary, is frequent in medical students and negatively affects student wellness. Methods The aspects of impostorism that were most prevalent in medical students during the transition from the preclinical to clinical phases of their training were assessed using an anonymous, voluntary 60-item survey that included the Clance Impostor Phenomenon Scale (CIPS) and a 2-item burnout assessment administered in October-November 2018. Ratings of individual CIPS items were compared between items for the entire sample and in subpopulations of students. The correlation of individual CIPS items with CIPS total score was also determined. Results A total of 127 of 215 (59%) surveyed students responded, with 112 completing the CIPS with mean score of 63.0 ± 14.6 (moderate-to-frequent impostor feelings). Ratings of individual CIPS items differed significantly between items. Responses also differed depending on gender and perceived burnout or depersonalization. Discussion Third-year medical students identified most strongly with items related to unfounded fear of failure, hesitance to share recognition before it is announced, remembering failures rather than successes, believing themselves less capable than others, and worrying about succeeding. In contrast, attribution of accomplishments to luck was not prominent for these students. Responses to certain items also differed depending on gender and perceived burnout or depersonalization, but not self-reported under-represented minority status. This observation may inform the development of interventions tailored to foster wellness as students negotiate the transition from the preclinical to clinical phases of their training. Electronic supplementary material The online version of this article (10.1007/s40037-020-00562-8) contains supplementary material, which is available to authorized users.

Background Intrathecal fluorescein (IF) has become a common tool for localization of cerebrospinal fluid (CSF) leak, but despite frequent use, IF lacks Food and Drug Administration approval. The diagnostic ability of high-resolution computed tomography (HRCT) has increased over several decades. Subspecialized rhinology training within otolaryngology has, similarly, allowed for dedicated skull base surgeons to become more adept at CSF leak localization. Objectives To evaluate the utility of HRCT and IF in CSF leak localization. To identify certain patient populations in which IF has added utility. To analyze the ability of fellowship-trained neuroradiologist and rhinologist to localize CSF leak sites. Methods Data were collected from a single, tertiary care academic institution. Patients admitted for CSF leak between 2003 and 2016 were included. Diagnostic yield of preoperative imaging and IF for identification of leak site was analyzed. Fellowship-trained neuroradiologist and rhinologist performed retrospective review of CT imaging and identified CSF leak sites. Results One hundred and two patients underwent CSF leak repair. Skull base defects were preoperatively localized to exact sinus on imaging report in 67% of patients. Preoperative imaging stratified by CT slice thickness of 0.625 mm identified leak site in 88.9% of cases. Blinded retrospective review by a neuroradiologist and rhinologist was able to localize the CSF leak to the correct or adjacent sinus in >80% of cases. IF was useful for intraoperative localization in 73% of cases. When preoperative imaging failed at leak site localization, IF was able to correctly identify leak site in 75% of cases. Conclusions The diagnostic yield of IF and CT imaging was equivalent, with each modality localizing leak site approximately two-thirds of the time. CT imaging with 0.625 mm slice thickness proved more efficacious in identification of skull base defects. IF demonstrated increased utility in instances where preoperative imaging has failed at leak site identification.

Prescription drug stewardship is critical. Autopopulation(AP) of medication quantities may influence prescriber behaviour. We investigate the impact of AP removal(APR) on opioid prescribing.Inpatient and emergency department(ED) discharges with opioid pain medications 2 years before and after APR were identified. Milligrams of morphine equivalents(MMEs) prescribed were recorded. Group comparisons were performed using Mann-Whitney U tests. Spearman's rho was used to analyse correlations between pain level and quantity of prescribed opioids. Mann-Kendall tests assessed trends in prescription patterns. Generalized estimating equations assessed trends in total quantity of prescribed MME.A total of 53 608 patient encounters were included for analysis. In surgical patients, there were no trends in the frequency of prescriptions below, at or above the AP quantity pre-APR. Post-APR, there was a decrease in the percentage of prescriptions written for the AP quantity(τ = -.493, P = .001) and an increase in prescriptions for30 tablets(τ = .468,P = .001). In non-operative patients, the pre-APR period was associated with a lower percentage of prescriptions30 tablets and a greater percentage of prescriptions for30 tablets. Interestingly, APR reversed this trend in prescriptions for30 tablets and resulted in an increase in larger prescriptions. Multivariate analysis of the total prescribed quantity of MME found no significant trend across months for inpatients prior to and after APR (0.997, P = .065 and 1.003, P = .142; respectively). The ED model found a monthly downward trend in amount of prescribed MME prior to and after APR (0.986, P .001 and 0.990, P .001; respectively). In the inpatient setting, pain was positively correlated to discharge MME (ρ = .028, P .001); with those reporting the highest pain receiving the greatest amount of opioids both pre- and post-APR. Interestingly, in the ED, this finding was negatively correlated (ρ = -.086, P .001); with those reporting the lowest pain receiving the greatest amount of opioids both pre- and post-APR.AP removal may have unintended consequences, such as increased prescriptions for greater quantities. To drive down prescription amounts, lower anchor values may be of more utility than APR. The poor correlation of pain values with prescribed medications warrants further investigation.

Background: Olfactory dysfunction is an important facet of numerous disease states ranging from sinonasal disease to neurocognitive disorders. Due to expense and/or logistical barriers, objective olfactory testing is not common. We describe the creation of a novel, essential oil-based smell test, Affordable Rapid Olfaction Measurement Array (AROMA), composed at 14 scents at different concentrations and demonstrate correlation of AROMA with the University of Pennsylvania Smell Identification Test (UPSIT), patient age, Sinonasal Outcomes Test (SNOT-22), and perceived loss of smell. Methods: AROMA was developed for point-of-care olfactory testing and compared to the UPSIT, as well as subjective outcome measures as noted above. About 37 healthy controls were prospectively recruited to assess the reliability of AROMA using a test–retest protocol. An additional cohort of 38 participants with sinonasal disease were prospectively recruited to complete the AROMA and UPSIT, and were compared with a cohort of 30 healthy controls. Spearman correlation correlated AROMA and UPSIT results, patient age, SNOT-22, and perceived loss of smell. Results: AROMA demonstrated good test–retest reliability ( r = 0.85, P < .001). Spearman’s rho correlation of AROMA to UPSIT was statistically significant at ρ = 0.75 ( P < .001). SNOT-22, age, and perceived sense of smell were all significantly correlated with both AROMA (ρ = −0.548, −0.557, −0.642, respectively) and UPSIT (ρ = −0.367, −0.460, −0.552, respectively). Conclusion: AROMA has a strong correlation with UPSIT and may be more strongly correlated with sinonasal outcomes. Additionally, AROMA is reusable; level of odorant is not static; and AROMA can test both odor detection and identification. Level of evidence: 2b

The residency selection process is challenging for both applicants and programs. This is particularly true in competitive specialties such as otolaryngology. The importance of noncognitive competencies in successful residents has been well demonstrated in both medicine and surgery. Unfortunately, there is no streamlined or uniform process for incorporating this information into the selection and training of residents. This review provides a summary of innovative approaches in the selection of residents in otolaryngology and the important role these methods and associated data can play in resident selection and training. The goal of these processes is to create a holistic view of potential residents so programs can enhance the development of current residents and boost long-term success in our specialty. Laryngoscope, 130:65-68, 2020.

Introduction: Functional pain assessments are critical in total hip arthroplasty. This pilot study investigated a novel functional pain scale—the Activity-Based Checks of Pain (ABCs)—and its correlations with the 0 to 10 numeric rating scale (NRS) and outpatient milligram of morphine equivalents (MMEs) prescribed and needed in the first 2 weeks after total hip arthroplasty. Methods: ABCs and NRS were collected at the baseline, inpatient, and 2-week follow-up. Primary outcome metrics were needed for pain medication at the time of pain scale completion, MMEs prescribed at discharge, and MMEs taken. Individual ABC functions and composite score were analyzed using Spearman rho and Mann-Whitney U tests Results: ABC and NRS scores were greatest preoperatively (n = 39). At each stage, the ABCs correlated with the NRS (ρ = 0.450, P < 0.01; ρ = 0.402, P < 0.05; and ρ = 0.563, P < 0.01). ABC or NRS scores did not correlate with MMEs prescribed. Last in-house NRS correlated with MMEs taken postoperatively (r = 0.571, P < 0.01). Specific ABCs functions—“sitting up” (ρ = 0.418, P < 0.01), “walking in room” (ρ = 0.353, P < 0.05), and “walking outside room” (ρ = 0.362, P < 0.05)—on the day of discharge correlated with MMEs taken. Conclusion: ABCs scale correlates with NRS. Neither scale correlated with MMEs prescribed at discharge, suggesting pain is undervalued in analgesic planning. Clinicians should assess pain with functions found to correlate with MMEs taken—“sitting up,” “walking in room,” and “walking outside room.”

Background Informed consent is an integral part of pre-operative counseling. However, information discussed can be variable. Recent studies have explored the use of multimedia in providing informed consent for rhinologic surgery. Objective To measure impact of an educational video (Video) compared to verbal informed consent (Verbal) on knowledge gained, alleviation of concerns, and efficiency. Methods Patients undergoing endoscopic sinus surgery (ESS), septoplasty, or ESS+septoplasty were prospectively enrolled and randomized to receive Video or Verbal consent. The Video group watched an educational video; the Verbal group received standard verbal consent from an Otolaryngology resident per institutional protocol. Both groups had the opportunity to discuss questions or concerns with their attending surgeon. Prior to, and after, consent was signed, both groups completed surveys regarding knowledge of purpose, risks, and benefits of surgery as well as surgical concerns. Decision regret and patient satisfaction were also assessed post-operatively. Results 77 patients were enrolled (39 Video, 38 Verbal). Demographics were not significantly different between groups. Overall knowledge significantly improved (p Conclusion Use of an educational video was equivalent to standard verbal informed consent for patients undergoing rhinologic surgery. Otolaryngologists can consider developing procedure-specific videos to allow allocation of time to other tasks, standardized education of patients, and streamlining of the informed consent process.

Objectives To further demonstrate the validity of Affordable Rapid Olfaction Measurement Array (AROMA), an essential oil−based smell test, and compare it to the Sniffin’ Sticks 12 Test (SST12). Study Design Prospective cross-sectional study. Setting Academic medical center. Methods Fifty healthy individuals without sinonasal disease were recruited to the study. AROMA has been previously validated against the University of Pennsylvania Smell Identification Test. The current study tests 2 additional higher concentrations to increase the ability to detect olfactory reserve. Healthy participants completed AROMA, SST12, Sino-Nasal Outcome Test (SNOT-22), and Questionnaire of Olfactory Disorders (QoD). Spearman correlations were used to evaluate AROMA, SST, SNOT-22, and QoD. Results AROMA demonstrated strong test-retest reliability ( r = 0.757, P < .01). AROMA showed a moderate correlation to SST12 (ρ = 0.412, P < .01). Age and SNOT-22 were significantly correlated ( P < .05) with AROMA (ρ = −0.547, −0.331, respectively), and age was weakly correlated with SST (ρ = −0.377, P < .01). Median percent correct scores were as follows: SST12 identification, 92%; AROMA detection, 90%; and AROMA identification, 81%. Median correct odor identification of AROMA concentrations at 1×, 2×, 4×, and 8× were 64%, 75%, 92%, and 92%, respectively. Conclusion AROMA has a moderate correlation with SST12. AROMA is more strongly correlated than SST12 to age and SNOT-22. AROMA’s stronger correlation with subjective olfactory status, low cost, and adaptability may help remove barriers to routine olfactory testing in the clinic.

Otolaryngology has historically lagged behind other specialties with respect to diversity, equity and inclusion (DEI) and remains one of the least diverse specialties as it relates to gender, race and ethnicity. Strategies aimed at increasing DEI include programs designed to provide mentorship, coaching, and sponsorship. Pipeline efforts, inclusivity on committees, bi-directional communication, and equal pay are additional DEI efforts that have been successful in recruiting and retaining those under-represented in medicine (URiM). Closing the equity gap requires commitment; daily action and measuring progress is required. Finally, use feedback to make refinements as opportunities exist to continually improve DEI efforts.

To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions.Cross-sectional analysis of US national database.American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017.A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared.When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis.We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

Dissemination and implementation (DI) science analyzes interventional strategies that aid in spreading scientific knowledge, adopting evidence into practice, and identifying barriers to maximize successful integration of science into practice. This study set out to critically appraise the published DI strategies of the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) Clinical Practice Guidelines (CPGs) and to introduce the theories of DI science.The 15 AAO-HNSF CPGs underwent appraisal by 2 independent reviewers using the Appraisal of Guidelines for ResearchEvaluation II (AGREE II) instrument. CPGs were rated over 23 key items in 6 domains. Each item was rated on a 7-point scale from 1 (The overall mean score of the CPGs was 85.2% (95% confidence interval, 83.4%-86.9%). Individual CPG mean scores ranged from 80.4% to 90.9%. Mean interrater reliability was strong. All domains of the AGREE II instrument, except the Applicability domain, scored a mean of 90.7% or better. DI strategies within the CPGs, as calculated by the Applicability domain score, ranged from 22.9% to 77.1%.There is a paucity of published DI strategies within the AAO-HNSF CPGs. Nesting a DI framework, such as the Quality Improvement Framework, within CPGs would allow for identification of barriers to CPG adoption and evaluation of CPG-directed interventions.A DI framework within the AAO-HNSF CPGs would allow for objective measurement of the overall impact of CPGs on otolaryngology practices.

It is unknown the optimal extent of sinus surgery in pediatric patients with orbital cellulitis. Our aim was to determine the nationwide incidence of sinus procedures used to treat pediatric orbital cellulitis. Additionally, we sought to identify patient-factors that influence a multi-procedural approach.Cross-sectional analysis of 15,260 cases of primary pediatric orbital cellulitis identified in the Kids' Inpatient Database (KID) from January 1, 2003 to December 31, 2012. Cases were included if they contained a primary diagnosis code of orbital cellulitis. Frequency of sinus procedures in relation to pediatric age cohort were noted (≤8 years versus 9-20 years). Comorbidities, cost, and length-of-stay were compared between age cohorts. Multivariate models investigated patient-factors associated with multiple sinus procedures and patient-factors that affected hospital costs and length-of-stay.Children ≤8 years of age constituted 67% of cases (n = 10,290). 1103 cases (7.2%) were treated with at least one defined sinus procedure; and, 712 of these cases documented more than one sinus procedure. The younger cohort (≤8 years) exhibited fewer sinus procedures and a lower rate of reoperation (4.6% vs 12.8%, p .001; 5.1% vs 7.7%, p .001, respectively). Presence of cellulitis/abscess of the face was the strongest predictor of multiple sinus procedures (OR = 1.982, p = .033). Patients with acute sinusitis and those8 years had similarly increased odds of a multi-procedural approach (OR = 1.333, p = .049; OR = 1.367, p = .032, respectively). Multivariate analysis of cost and length-of-stay found that patients8 years incurred 14% longer hospital stays and an increase in costs of 9% compared to younger patients (p = .001, p = .039; respectively). The secondary diagnosis with the largest effect on length-of-stay and cost was an intracranical abscess (OR = 2.352, p .001; OR = 2.752, p .001; respectively).In a nationwide population of pediatric patients with primary orbital cellulitis there was an incidence of sinus surgery in 7.2% of cases - with patients over 8 years having a 2.8-fold increase compared to younger patients. Additionally, nearly two-thirds of patients treated with sinus surgery had multiple sinus procedures. The high incidence of multiple sinus procedures suggests that further prospective studies are needed to elucidate the extent of drainage associated with the best patient outcomes.

Nasal obstruction is a common symptom and can have a large impact on patient quality of life. There are numerous causes, including anatomic, congenital, inflammatory, infectious, neoplastic, toxic, and systemic. An algorithmic approach can aid in ensuring all pertinent patient information is incorporated into the final diagnosis and treatment plan. Key components include a thorough history, physical examination including modified Cottle and Cottle maneuver, patient-reported outcome measures and/or quality of life questionnaires, examination with and without decongestion, and nasal endoscopy. The resultant information can then be effectively used to narrow the differential and guide the next steps in management.

BACKGROUND If conservative management of CSF leak is unsuccessful, surgical repair is indicated for the prevention of severe complications such as meningitis. This study investigated the influence of surgical timing on clinical and economic outcomes. METHODS Retrospective review of the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2002-2011) for nonelective admissions with a principal diagnosis of CSF rhinorrhea treated with surgical repair of the meninges. Demographics and outcomes of patients undergoing meningeal repair for CSF rhinorrhea were analyzed. Cases were classified into four groups based on timing of surgical intervention: 1) performed on the day of admission (day 0), 2) performed between days 1 and 3, 3) performed between days 4 and 7, and 4) performed between days 8 and 14. RESULTS A total of 1,088 emergent admissions were analyzed. On average, patients underwent surgical repair between the second and fourth day of admission. Lowest rates of meningitis were in patients treated on the day of admission (6.1%); those treated at 2 weeks had a 34.7% incidence. Multivariate analysis controlling for comorbidity burden, gender, and surgical timing found the highest odds of meningitis in patients treated with surgical repair during the second week of admission compared to repair on the day of admission (OR 8.2, P

Objective: Health registries and discharge-level databases are powerful tools. Commonly used data sets include the Nationwide Inpatient Sample (NIS); Surveillance, Epidemiology, and End Results Program (SEER); National Cancer Database (NCDB); and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This study investigated the frequency with which these resources are being used and categorized their contributions to literature. Design: A literature review from 2005 to 2016 for papers utilizing the aforementioned databases and publishing in The Laryngoscope, JAMA-Otolaryngology, Head and Neck, Otolaryngology-Head and Neck Surgery, and International Forum of Allergy and Rhinology was conducted. Results were categorized based on the contribution(s) of the paper. The incidence rate of database publications was calculated for each year along with the 95% confidence intervals using a Poisson distribution. Results: Three hundred ten studies were identified. Seventy percent report descriptive findings, and 65% report outcomes/survival. Approximately 18% made clinical recommendations. In 2005, the incidence rate of database publications was 3 per 1000 journal publications (95% CI, 1-9) and remained relatively stable until 2008. From 2010 onward, there was a persistent increase in publications, culminating in the highest incidence rate in 2016 of 26 database publications per 1000 journal publications (95% CI, 20-32). Conclusions: There was a nearly 10-fold increase in database publications in 2016 compared to 2005. The majority provide descriptive data and outcomes measures. The role of these studies warrants further investigation.

Objectives The number of transsphenoidal adenohypophysectomies (TSAs) surgeries has grown significantly since 1993. While there has been an overall decreasing trend in length of stay (LOS), socioeconomic factors may impact hospitalization. This study explores the impact of socioeconomic factors on LOS and total charges in uncomplicated patients undergoing TSA. Design Retrospective cohort. Setting 2009 to 2013 Nationwide Inpatient Sample. Participants Patients undergoing TSA without medical complications. Main Outcomes Measures LOS and total charges. Results A total of 6,457 patients were identified, of which 17.2% had secreting tumors. Patients with secreting tumors stayed 2.95 days versus those with nonsecreting tumors stayed 3.26 days (p Conclusions These results demonstrate that, even without complications, patients can be delayed in their discharge. While several socioeconomic factors significantly predict LOS and charges, the discharge disposition ultimately has the greatest effect. This suggests that efforts should focus on improving organizational factors such as coordination with social work and outside facilities to decrease LOS and charges for this patient population.

Botulinum toxin is the most commonly performed facial cosmetic procedure and pain at the injection site is a frequent patient concern. While various topical interventions have been described for analgesia, there have not been any studies comparing different techniques. We compared the use of a vibratory stimulus, ice pack application, and no intervention on injection site pain for cosmetic botulinum toxin injection. A prospective-, randomized-, individual-controlled study was conducted using a visual analog scale to assess pain. Patients received bilateral glabellar injections, with randomization into unilateral vibration, unilateral ice application, or vibration and ice on either side. We analyzed 88 injections on 22 patients. Mean visual analog scores were 26.5 (standard deviation [SD]: 23.1) among injections with vibration, 24.4 (SD: 22.9) with ice, and 29.4 (SD: 27.1) without analgesia. There was no significant difference in pain scale scores with the use of vibration, ice, or no topical anesthesia ( P = .737). Further, pain scale scores did not differ significantly between medial and lateral injections nor did patients have a reduction in pain on either side of the forehead regardless of which method was used. While there may be a role for topical interventions to improve injection site analgesia, we maintain that consistently proper technique plays a greater role in improving patient tolerance. Future studies will continue to investigate the role of topical anesthesia in cosmetic facial injections and address patient-specific factors contributing to discomfort.

IMPACT: Better understanding how clinicians make decisions about pain management, particularly since our prior research has demonstrated that opioids prescribed at discharge is the strongest predictor of opioids taken, is critical to decrease high-risk medication prescribing while preserving high-quality care. OBJECTIVES/GOALS: (1) Identify major biological, psychological, and social determinants of medical and surgical residents’ pain management decisions; (2) Determine salient themes regarding the experience of residents in the management of acute and chronic pain METHODS/STUDY POPULATION: Focus groups of internal medicine and general surgery residents at an academic, tertiary care training hospital located in an urban setting were conducted. Due to the COVID-19 pandemic, all focus groups were conducted virtually and occurred during required didactic sessions to facilitate participation. All interviews were recorded and transcribed. Two reviewers independently reviewed and coded the data following the principles of constructivist grounded theory. RESULTS/ANTICIPATED RESULTS: 42 residents participated in ten focus groups ranging in size from two to five individuals. Six themes emerged demonstrating salient BPS factors in pain management decisions: (1) patient and clinician expectations determine what is considered normal/acceptable; (2) inability of pain scales to reliably capture patient pain; (3) desire for more objective methods of pain assessment, while simultaneously recognizing that pain is an inherently subjective experience; (4) difficulty in determine when pain is 'real’ or 'legitimate'; (5) lack of education and protocols regarding pain management; (6) the importance of engaging other services such as acute pain service or nurse educators in complicated situations. Junior residents often expressed doubt in the appropriateness of their approaches and decisions. DISCUSSION/SIGNIFICANCE OF FINDINGS: Surgical and medical trainees routinely treat pain and may struggle, particularly in the early phases of training, to determine if pain levels are appropriate. There is also a lack of education and/or best practices for assessing and managing pain. These areas represent high-value, clinician-focused targets for future interventions to improve care.

Objectives To describe levels of burnout and impostor syndrome (IS) in medical students, and to recognize demographic differences in those experiencing burnout and IS. Methods Research participants included 2,612 medical students who entered Jefferson Medical College between 2002 and 2012. This sample was divided into two groups: Matriculants between 2002 and 2007 (n=1,380) and between 2008 and 2012 (n=1,232). Data for 2002-2007 matriculants were subjected to EFA (principal component factor extraction), and data for matriculants of 2008-2012 were used for CFA (structural equation modeling, and root mean square error for approximation). Results One hundred and thirty-eight students completed the questionnaire. Female gender was significantly associated with IS (χ2(3)=10.6, p=0.004) with more than double the percentage of females displaying IS than their male counterparts (49.4% of females versus 23.7% of males). IS was significantly associated with the burnout components of exhaustion (χ2 (2)=5.9, p=0.045), cynicism (χ2(2)=9.4, p=0.004), emotional exhaustion (χ2(2)=8.0, p=0.018), and depersonalization (χ2 (2)=10.3, p=0.006). The fourth year of medical school was significantly associated with IS (χ2(3)=10.5, p=0.015). Conclusions Almost a quarter of male medical students and nearly half of female students experience IS and IS was found to be significantly associated with burnout indices. Given the high psychological morbidity of these conditions, this association cannot be ignored. It behooves us to reconsider facets of medical education (i.e. shame-based learning and overall teaching style) and optimize the medical learning environment.

Background:Cervicofacial actinomycosis is an uncommon indolent infection caused by Actinomyces spp that typically affects individuals with innate or adaptive immunodeficiencies. Soft tissues of the face and neck are most commonly involved. Actinomyces osteomyelitis is uncommon; involvement of the skull base and temporal bone is exceedingly rare. The authors present a unique case of refractory cervicofacial actinomycosis with development of skull base and temporal bone osteomyelitis in an otherwise healthy individual.Methods:Case report with literature review.Results:A 69-year-old man presented with a soft tissue infection, culture positive for Actinomyces, over the right maxilla. Previous unsuccessful treatment included local debridement and 6 weeks of intravenous ceftriaxone. He was subsequently treated with conservative debridement and a prolonged course of intravenous followed by oral antibiotic. However, he eventually required multiple procedures, including maxillectomy, pterygopalatine fossa debridement, and a radical mastoidectomy to clear his disease. Postoperatively he was gradually transitioned off intravenous antibiotics.Conclusions:Cervicofacial actinomycosis involves soft tissue surrounding the facial skeleton and oral cavity and is typically associated with a history of mucosal trauma, surgery, or immunodeficiency. The patient was appropriately treated but experienced disease progression and escalation of therapy. Although actinomycosis is typically not an aggressive bacterial infection, this case illustrates the need for prompt recognition of persistent disease and earlier surgical intervention in cases of recalcitrant cervicofacial actinomycosis. Chronic actinomycosis has the potential for significant morbidity.

OBJECTIVES/HYPOTHESIS To develop a "word cloud"-based visual letter of recommendation (VLOR) and to evaluate its efficiency in discerning applicant quality compared to narrative letters of recommendation (NLORs). STUDY DESIGN Cross-sectional cohort study. METHODS NLORs for 48 otolaryngology residency applicants interviewed from the 2016 application cycle were identified and mined for descriptive terms to generate a word cloud, referred to as a VLOR. Eight individuals reviewed and rated a total of 187 blinded NLORs and 48 VLORs on a four-point scale (negative to exceptional). Median VLOR and NLOR scores and the time to review for each candidate were compared using the Wilcoxon signed rank test. RESULTS It took significantly more time to review the NLORs in comparison to the VLORs (67 seconds, interquartile range [IQR]: 41-98 seconds vs. 17 seconds, IQR: 11-26 seconds, P

Background Pain gained recognition as a vital sign in the early 2000s, underscoring the importance of accurate documentation, characterization, and treatment of pain. No prior studies have demonstrated the utility of the 0–10 pain scale with respect to discharge opioid prescriptions, nor characterized the most influential factors in discharge prescriptions. Methods Inpatient and emergency department(ED) encounters from July 1, 2012 to April 1, 2018 resulting in a discharge prescription for tablet opioid medications were identified. The primary outcome was to determine if pain levels in 24 h prior to discharge correlated with opioids (in milligrams of morphine equivalents (MME)) prescribed. Secondary outcomes included the impact of patient and prescriber demographics, demographics. A generalized linear model was created to investigate factors affecting the quantity of prescribed opioids. Results n = 78,691 patient encounters. Overall mean adjusted MME for non-ED visits was 378 versus 197 for ED visits. Whites received the highest quantities; those identifying as non-white and non-black received the lowest. Women received significantly fewer discharge MMEs in both the ED and inpatient cohorts. Provider prescribing patterns exhibited the most profound effect on discharge MMEs. The most prolific (≥300 prescriptions over the study period) writing the largest amount. In the ED, there was a significant negative correlation between documented pain levels and discharge MMEs(ρ = 0.074,p Conclusions Pain scale was significantly negatively correlated with discharge MMEs in the ED and positively correlated in the inpatient population. Individual prescriber characteristics were the more influential variable, with prolific high prescribers writing for the largest MME amounts. The inverse association of pain and MMEs at discharge in the ED, and the large effect pre-existing prescriber patterns exhibited, both improved methodology for assessing and appropriately treating pain, and effective prescriber-targeted interventions, must be a priority.

If conservative management of CSF leak is unsuccessful, surgical repair is indicated for the prevention of severe complications such as meningitis. This study investigated the influence of surgical timing on clinical and economic outcomes.Retrospective review of the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2002-2011) for nonelective admissions with a principal diagnosis of CSF rhinorrhea treated with surgical repair of the meninges. Demographics and outcomes of patients undergoing meningeal repair for CSF rhinorrhea were analyzed. Cases were classified into four groups based on timing of surgical intervention: 1) performed on the day of admission (day 0), 2) performed between days 1 and 3, 3) performed between days 4 and 7, and 4) performed between days 8 and 14.A total of 1,088 emergent admissions were analyzed. On average, patients underwent surgical repair between the second and fourth day of admission. Lowest rates of meningitis were in patients treated on the day of admission (6.1%); those treated at 2 weeks had a 34.7% incidence. Multivariate analysis controlling for comorbidity burden, gender, and surgical timing found the highest odds of meningitis in patients treated with surgical repair during the second week of admission compared to repair on the day of admission (OR 8.2, P .001). Length of stay (LOS) and hospital costs increased as time to repair increased.Multiple factors influence outcomes in patients with CSF rhinorrhea. Early surgical repair was significantly associated with decreased rates of meningitis, LOS, and hospital costs. Expedient treatment of patients admitted for CSF rhinorrhea may prove to be both a cost- and morbidity-saving measure.2C Laryngoscope, 129:539-543, 2019.

BACKGROUND Previous studies have demonstrated a high failure rate of endoscopic sinus surgery (ESS) with Draf IIa in patients with diffuse polyposis, asthma, and aspirin-exacerbated respiratory disease. A high percentage of these patients progress to endoscopic modified Lothrop procedure (EMLP). We describe a modification of the Draf IIb with a superior septectomy (IIb+SS), which may provide similar therapeutic benefit as demonstrated by the distribution of sinus irrigations in the sinus cavity with ESS with IIb+SS vs ESS with EMLP. METHODS ESS with IIb+SS was performed on 6 cadaver heads. Fluorescein-dyed irrigations were performed on each head and penetration was recorded using video endoscopy. EMLP was subsequently performed on each head with repeat dye-irrigation and video endoscopy. The videos were reviewed by 4 blinded fellowship-trained rhinologists, and irrigant penetration of the maxillary, ethmoid, frontal, sphenoid sinuses, and olfactory cleft was graded 0 to 3 (3 implying complete staining). RESULTS The mean scores when comparing IIb+SS to EMLP were as follows: overall 1.99 vs 1.97 (p = 0.816), maxillary sinus 2.67 vs 2.38 (p = 0.128), ethmoid sinus 1.88 vs 1.98 (p = 0.536), sphenoid sinus 2.58 vs 2.50 (p = 0.467), frontal sinus 1.13 vs 1.38 (p = 0.073), and olfactory cleft 1.71 vs 1.63 (p = 0.529). There was no significant difference between subsites. Interrater reliability was good (Cronbach's alpha = 0.781). CONCLUSION Performing ESS with IIb+SS provides similar irrigation delivery benefits to ESS with EMLP, without the need for altering natural sinus outflow and creating circumferential scarring. Further studies evaluating its use in patients that are high risk for revision surgery are needed.

Background Efficient, nonbiased methods for screening residency candidates are lacking. The purpose of this study is to highlight the design, implementation, and impact of the Selection Tool for Applicants to Residency (STAR), an objective approach to selecting candidates to interview for residency selection purposes. Materials and methods Single-institution retrospective cohort study of medical student applicants and current residents of a single otolaryngology residency program from 2008 to 2015 was performed. STAR was introduced to the selection process in 2013 with no USMLE cutoff score needed to receive an interview. Single-institution review of otolaryngology residency program applications from 2008 to 2015 was performed. STAR was introduced in 2013. In addition to applicants, we analyzed characteristics of residents who successfully matched into our program. Prealgorithm residents (n = 16) and postalgorithm residents (n = 12) were compared to assess the impact of this approach on characteristics of successfully matched residents at the program. Results Three hundred sixty-five applications were analyzed. Applicant pools before and after algorithm displayed similar characteristics. Interestingly, while there was no USMLE “cutoff,” scores significantly increased after algorithm. There was no significant difference in the proportion of women (P = 0.588) or underrepresented minorities (P = 0.587) invited to interview pre- and post-STAR. The algorithm significantly decreased the time needed to review applications and interview residency candidates without impacting the overall composition of the interviewee pool. Conclusions Traditional application review methods can be time consuming and may not ensure effective screening of applicants. STAR, or similar objective tools, may be a viable alternative to evaluate applicants, reduce evaluative time, and potentially decrease the impact of unconscious bias.