Cynthia Shen

Implication Statement Augmented reality (AR) telementoring offers a novel approach to delivering real-time procedural instruction to learners in remote and austere environments. By enabling faculty to annotate a learner’s field of view, overlay visual guides, and provide live audio coaching, AR can extend the reach of procedural training without requiring in-person presence. In this pilot, we demonstrate the feasibility of AR telementoring for visually guided, tactile procedures such as escharotomy, while highlighting important challenges for complex, image-dependent tasks such as ultrasound-guided central venous access. With intentional alignment between procedure type and technological capabilities, AR telementoring may help reduce instructional inequities across geographically dispersed medical education sites.

Introduction: Early leadership development is an increasing focus in both military and civilian undergraduate medical education, where physicians are expected to lead multidisciplinary teams and perform under complex, high-stakes conditions. Despite a growing number of leadership training programs, few studies have evaluated the longitudinal progression of leadership competencies across medical school using standardized, validated tools. The Uniformed Services University (USU) has implemented a longitudinal leadership curriculum grounded in the Leader-Follower (LF2) Framework, which includes 4 core elements: Character, Competence, Context, and Communication. This study aimed to determine whether leadership performance during a third-year immersive field practicum (Operation Gunpowder) correlates with and predicts subsequent performance in a fourth-year practicum (Operation Bushmaster) using the same standardized assessment approach. Materials and Methods: This observational cohort study included 151 students from USU’s class of 2025 who completed both military field practicums (MFP). Both MFPs assessed students using a validated 5-item leadership evaluation tool aligned with the LF2 framework. Each element was rated on a 4-point Likert scale. Pearson correlation coefficients were calculated to assess associations between MFP leadership scores. Best subset regression was used to identify which Gunpowder leadership elements best predicted Bushmaster performance. The study was approved by the USU Institutional Review Board (Protocol Number: KM83XV). Results: The total leadership score from Gunpowder was positively correlated with the total score from Bushmaster. Among individual elements, only Leadership Transcendent Skills (LTS) and Role-Specific Competence during Gunpowder showed positive correlations with their corresponding Bushmaster scores. LTS in Gunpowder was significantly correlated with all 5 leadership elements in Bushmaster, while Role-Specific Competence correlated with all Bushmaster elements except Communication. Regression analysis identified LTS as the strongest and most consistent predictor of Bushmaster performance across multiple domains, including Character, Communication, and LTS itself. In contrast, Role-Specific Competence from Gunpowder only predicted the same element in Bushmaster. The overall Gunpowder sum score was not a significant predictor of any individual Bushmaster element. Conclusions: This study demonstrates that specific leadership traits assessed early in medical school, particularly LTS, predict future leadership performance in operationally realistic environments. The cross-domain predictive power of LTS suggests it may serve as a transferable core skill analogous to Trait Emotional Intelligence (Trait EI), reinforcing its potential value in early leadership curricula. In contrast, Role-Specific Competence appeared to be context-bound and limited in broader predictive impact. A key strength of this study is its use of standardized, longitudinal, non-self-report assessment data within a single institution’s evolving yet consistently framed leadership curriculum. Limitations include the single-institution design and lack of post-graduate performance data. Future studies should assess reproducibility across cohorts, examine long-term predictive value into residency, and explore generalizability to civilian training programs.

Introduction: Peer role-playing, in which medical students alternate between provider and patient roles, is a core component of peer-assisted learning. While the educational value of playing the provider is well established, the extent to which students gain medical knowledge through acting as patients remains unclear. Methods: In this quantitative study with qualitative components, 178 first-year medical students portrayed patients during a high-fidelity prehospital simulation. Medical knowledge was assessed with a 21-item multiple-choice test after simulation (162 responses; 91.0% response rate). An open-ended reflection prompt captured students' perceived learning. Chi-square analyses compared knowledge performance between students who portrayed a given scenario (“Actors”) and those who did not (“nonactors”). Qualitative data were analyzed using reflexive thematic analysis. Results: Quantitative analysis revealed no statistically significant differences in performance between actors and nonactors across test items ( P = 0.17–0.99). However, 160 students (89.9%) reported perceived gains in medical knowledge. Thematic analysis identified 3 primary learning mechanisms: observational learning, experiential learning, and direct instruction. Conclusions: Although knowledge gains specific to patient roles were not captured through multiple-choice testing, students perceived substantial learning through peer role-play. The student-as-patient role may be intentionally designed to support cognitive as well as affective learning in simulation-based medical education.

Introduction: Military medical students train in austere, high-stress environments that simulate prolonged casualty care and the cognitive and emotional demands of combat medicine. These scenarios can heighten stress and cognitive load, yet few curricula explicitly equip learners with structured strategies for psychological self-regulation. Mindfulness training has shown promise in clinical and operational contexts, but its educational role in military medical training is underexplored. Materials and Methods: We developed the Mental Strength and Resilience Training (MSRT), a brief, theory-informed mindfulness curriculum incorporating three 1-hour sessions and asynchronous video materials. Mental Strength and Resilience Training emphasized 5 mindfulness strategies—breathing, mantra, movement, stretching, and body scan—framed for transfer to prehospital operational environments. Ninety-seven third- and fourth-year medical students at the Uniformed Services University participated across 2 high-fidelity military medical field exercises: Operation Gunpowder (36 hours) and Operation Bushmaster (5 days). Outcomes were assessed with the Mindful Attention Awareness Scale (MAAS), Brief Resilience Scale (BRS), and Perceived Stress Scale (PSS) at 4 time points. These 4 time point measures were then analyzed using a repeated measures Analysis of Variance (ANOVA) model, and the relationships between each scale score were analyzed using correlations. Faculty observers also evaluated clinical performance at Operations Gunpowder and Bushmaster for all students. Performance comparisons between students involved in the study and students not involved were compared via independent samples t-testing. The relationships between study participants’ performance and their mindfulness, resilience, and stress were analyzed via correlations, with any significant correlations being entered into a regression model for further examination. This study was approved and deemed exempt by the Uniformed Services University Institutional Review Board (IRB) committee. Results: Learners demonstrated significant increases in mindfulness (η2p = 0.32, P < .001) and resilience (η2p = 0.06, P = .002), alongside reductions in perceived stress (η2p = 0.28, P < .001). Correlation analyses showed stress was consistently negatively associated with mindfulness and resilience. Faculty-rated performance scores did not differ significantly between the students involved in the study and non-participating students regularly enrolled at Operations Gunpowder and Bushmaster. However, pre-Bushmaster resilience predicted performance outcomes (P = .02) in the participating student sample. Conclusions: Brief, theory-informed mindfulness training enhanced learners’ self-regulation and reduced stress during high-fidelity military medical exercises. Although performance gains were not statistically significant, the findings suggest mindfulness is a feasible and scalable approach to strengthen psychological readiness in military medical education, with potential applications across military and civilian health professions training.

Introduction: Noncompressible torso hemorrhage (NCTH) is a major cause of preventable death in both civilian and military trauma settings. It involves vascular disruptions within the thoracic cavity, major axial torso vessels, severe solid organ injuries, or pelvic ring fractures leading to hemodynamic instability resistant to direct pressure control. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique used to temporarily occlude aortic blood flow, mitigating distal hemorrhage and preserving proximal perfusion until surgical intervention. This meta-analysis compares the effectiveness of REBOA with alternative surgical techniques in managing NCTH in trauma patients. Materials and Methods: A systematic review was conducted to investigate peer-reviewed studies on the outcomes of REBOA when compared to alternative surgical techniques in the management of NCTH. Databases searched include PubMed, Embase, Ovid EBM reviews (Cochrane), CINAHL, and Web of Science. The review included cohort, case-control, or randomized trials on patients 18 years or older with NCTH, comparing REBOA with alternative surgical techniques. Data on in-hospital mortality and acute kidney injury (AKI) were extracted. Critical appraisal of the risk of bias was assessed using the Cochrane Collaboration’s ROBINS-I tool. Statistical analyses were performed using R version 4.2.2. Results: Eight studies (n = 2,197) met the inclusion criteria. Resuscitative Endovascular Balloon Occlusion of the Aorta was associated with lower mortality compared to resuscitative thoracotomy and combined REBOA/thoracotomy, but higher mortality compared to pelvic angioembolization. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (p-REBOA) showed a significant reduction in AKI compared to full REBOA. No significant differences in AKI were found between REBOA and other treatments like preperitoneal packing or open aortic occlusion. Conclusions: Resuscitative Endovascular Balloon Occlusion of the Aorta may offer a survival advantage over resuscitative thoracotomy in NCTH management, but pelvic angioembolization may be more effective for pelvic trauma. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta is associated with a lower risk of AKI compared to full REBOA. The study is limited by the small number of included studies and heterogeneity. Further research, particularly randomized controlled trials, is needed to optimize NCTH treatment protocols, especially in military settings.

Introduction: Military medical providers must rapidly assess and treat casualties while managing prolonged care in resource-limited environments. Tactical Combat Casualty Care and Prolonged Casualty Care (PCC) provide structured frameworks for battlefield medicine, but training often separates technical and leadership development. To address this gap, Operation Gunpowder at the Uniformed Services University was adapted to integrate leadership and clinical skills. This study examines the relationships between student leadership performance, self-reported training experiences, and faculty and peer evaluations. Materials and Methods: This study analyzed data from 203 third-year medical and graduate nursing students participating in the 36-hour Operation Gunpowder field practicum. Leadership performance was assessed using the Leader-Follower Framework, which evaluates Character, Context, Competence, Communication, and Leadership Transcendent Skills. Students completed post-practicum surveys and reflections, and Pearson correlations were conducted between survey responses and leadership performance ratings. Qualitative responses were reviewed for themes related to quantitative findings. Results: In each squad, students who rated Primary Survey, Wound Care, or Evacuation Skills as useful had lower leadership performance scores, particularly in Character (r = −0.46 to −0.52, P < .05) and Communication (r = −0.46, P < .05). Confidence in PCC knowledge was positively correlated with adaptability (Context, r = 0.44, P < .05), suggesting that early PCC training may improve situational responsiveness. Squads that found hands-on practice most beneficial had lower Communication scores (r = −0.48, P < .05), indicating potential gaps in team coordination. Students who prepared for less than 1 hour before the practicum performed better in leadership dimensions, including Communication (r = 0.56, P < .01). Conclusions: These findings highlight challenges in integrating leadership into technical skills training. Enhancing PCC exposure, embedding communication exercises in hands-on training, and optimizing pre-practicum preparation may improve leadership development. Insights from this study can inform refinements to military medical training, including Operation Bushmaster, to better prepare future military medical officers for battlefield decision-making and leadership.