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Preface: This is a super long and very rough estimation of the potential risk that could be incurred by continuing to have students take their scheduled COMLEX Level 2 PE examinations this year. So, the NBOME today (via Dr. Gimpel) stated that the COMLEX Level 2 PE will not be canceled/suspended for the upcoming year, citing logistic issues as to why (less DO students in comparison to MD students, 25% of 2021 has already tested, etc. ) and then stated that the primary goal of the NBOME is safety of all its stakeholders. Seems empty to me. Even though I"m in the thick of Step 2 dedicated, I decided to do a little math to see what the risk of having DO"s complete the COMLEX Level 2PE in 2020-2021 would be. Number of 4th Year Osteopathic Medical Students Eligible for PE: - There were 7, 575 2017 enrollees - The historical attrition rate is about 3% per year. Couldn"t find data on 4-year graduation rate, but attrition rate seems to be about on par with MD students, whereas the AAMC found that 4-year graduation rate is about 81-84% for the time period 1994-2013. I"ll use 85% as an estimate (this won"t account for those who drop out this year or those who have changed classes based of research years, but I assume this is negligible). - 0. 85*7, 575*0. 75 (assuming Gimpel"s statement about 25% of students have taken it already) = 4, 829 students who will look to take the PE from July 1 2020 - May 1 2021 Coronavirus Infection and Complication Rates *( Calculating how many students actually would catch coronavirus is incredibly difficult, and would be minimized by social distancing efforts, masks, handwashing, and temperature screening) - Mortality Rate for Age 18-44: ~0. 2% - Current Coronavirus Picture: 1. 7M cases, 102K deaths - Some models project a 200K/day case rate in June. Making about 2. 1% of the population currently or previously positive for Covid-19. Some states have reported antibody positivity of about 10X what was previously reported. - Poor extrapolation of suspected current positivity of DO students ready to take PE by July: 0. 021*4, 829*10 = 1, 014 (meaning 3815 would not have any sort of immunity) Airport and Travel Statistics: (This is the most confusing and least known variable in my calculation. A lot of travel volume will depend on how Covid-19 plays out, and it will almost definitely fluctuate, like higher travel in summer vs winter, with high likelihood of another Covid-19 peak in flu season)* - Nevertheless, let"s try. I cannot predict how many students will travel by car. Out of the current 57 teaching locations for DO schools, 20 are in states that neighbor Illinois or Pennsylvania (where the testing centers are located). I could do a more stringent analysis, but let"s assume that about ~70% of students will need to fly (this is especially difficult to predict, because most DO schools use a distributive clinical model, and thus students are all over the place). (4, 829*0. 70 = 3, 380) - As of October 2018, there were 380 primary NPIAS airports (defined as having commercial and public traffic of 10, 000 or more enplaned passengers per year). - As of May 28, 2020, there were 321, 776 total passengers through US airports (about a 90% decrease from May 28, 2019). The average is about 250, 000 passengers per day over the last 2 weeks with an upward trend of about 300% 1 month prior (I"ll use 900, 000 passengers through US airports per day to accommodate fluctuations). This will likely increase however. - 900, 000/380 = 2, 368 estimated passengers on average traveling through every major airport each day, averaging about 2 passengers going through per minute (assuming most flights are happening from 4a-12a). - Most airlines suggest ariving at the airport an hour before your flight - Potential number of exposures while at airport (not counting staff you may encounter): 120 people - Average number of flights right now: 5, 670 (about 8. 5% of which are >70% full), with about every flight carrying on average about 40 people. - Potential Travel Exposure: 160*2 (for return flight) = 320 people *Calculation does not count arriving at your destination* Exposure While in City (this will vary based on whether you stay in hotels/hostels/with friends/family, etc. as well as for how long people stay and whether they go to restaurants and other public places; I"ll use just what we know) - Potential Testing Center Exposure: 12 people Total Potential Travel Exposure: 332 people per student (i. e. 332*3380 = 1, 122, 160 potential direct exposures) Final Risk Calculation: - Death Risk: <13. 1% of students would need to contract the virus while traveling for the PE in order to have <1 death associated with said travel. (500 students would have to contract it for 1 student to die, with a 0. 2% fatality rate for ages 20-39) - Complication Risk: No appreciable data, but there are reports of stroke, permanent lung damage, prolonged hospitalization, superinfection, and other pneumonia/SIRS complications. About 15% of the cases are serious or critical (and one small study detailing found reduced lung function after resolution). This statistic includes all cases, so it cannot be used to extrapolate complication risk in adolescents and young adults. There is ongoing research on coronavirus and its non-mortality effects. Conclusions: Requiring about 4, 000 students to travel for the COMLEX 2 PE puts DO students at risk until herd immunity is achieved and confirmed, and the longterm effects of Covid infection are delineated. Additionally, we don"t know the level of immunity that cases portend (especially mild or asymptomatic ones). In any case, there simply are too many unknowns for the NBOME to make definitive statements about requiring the PE for the 2020-2021 academic year, especially for a test that was only started in 2005 and that over 93% of students first-time pass in any given year. In addition, the test poorly represents actual practice, but rather is in place "to fulfill the public and licensing authority mandate for enhanced patient safety". Forcing students to take the PE this year seems counter to this goal. In regards to the Step 2 CS, it is "intended to determine whether physicians seeking an initial license to practice medicine in the United States, regardless of country of origin, can communicate effectively with patients. " The majority of students who successfully complete years 3 and 4 would likely meet this criteria as assessed by the new 2019 COMLEX blueprint. From a public health standpoint, one student death would reflect on average a loss of about 4200 patient visits per year (for attending primary care doctors) and a total waste of thousands of dollars in education spent on the individual, all for a $1300 dollar test. Potential Solutions: - Antibody test everybody prior and after PE - Require quarantining prior and after PE - Temperature screen for all students entering testing centers - Postpone PE until herd immunity is confirmed, and subsidize travel to and from during internship - Develop an agreement that all risk of infection, complication, and death is under the liability of the NBOME; treatment costs would also be covered by a secondary insurance plan - Develop a virtual exam for test-takers - Don"t require the CS/PE for 2021 graduates with or without refunds (at $1300*6439, the NBOME would lose $8, 370, 700 and I don"t see that happening), since USMLE said this doesn"t affect licensure I don"t understand the issue Final Word: I truly hope no one gets seriously sick or dies as a result of their PE. It simply would not be worth it. Also, this is completely in the perspective of students, what about our future patients we may be putting at risk? Final Final Word: Feel free to poke holes in this calculation. This was done very quickly. Limitations: - This calculation has major limitations due to methodology as well as data availability. Much of the calculation is performed based on current data and models that try to forecast how Coronavirus affects different aspects of our economy, transportation system, education, etc. As we"ve seen the last two months, this situation changes quickly. - I do not calculate how many people the students traveling would come into contact 2 weeks after their PE. In any case, all schools should encourage pre and post-PE antibody testing as well as a 2-week quarantine after their exam prior to going back on rotation. - Coronavirus data is very limited and is typically a reflection of what happened at least 2 weeks ago. There is little data on complications and fatality based on age and comorbidity. - This calculation does not account for secondary exposures through surface contact, potential previous exposures of the people students come into contact with while traveling, asymptomatic carrier risk, students with comorbid conditions, and many other factors. - Obviously, there is an inherent risk of traveling at all even in a normal year, and this calculation does not assess the statistical relationship between this year compared to previous years due to a paucity of similar analyses in the past. - Some airports will be much busier than others, while some airports may see a higher proportion of DO students traveling through them. Likewise, I cannot account for a potentially increased number of students deciding to drive to mitigate covid infection risk, but may increase overall risk due to motor vehicle crash risk. References: Osteopathic Medical School Enrollment and Number of DO Schools: | | | Attrition and 4-Year Graduation Rates: | COMLEX 2 PE and Step 2 CS Data: | | | | | Travel Data: | | | | | Coronavirus Data: | | | | | | | | | | | Edits: - Various grammar mistakes - incorrectly used 3815 instead of 3380 in the direct exposure calculation.
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