Doctors for the People:Training Physicians to Work in Under-served Urban Communities

Sherenne Simon, MPH, Matthew Anderson, MD, MS,Pablo Joo, MD

Department of Family & Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine

Project Aim

Montefiore’s Residency Program in Social Medicine (RPSM), established in 1970, trains clinicians to work in underserved communities.

In order to improve our own work we set about to examine similar programs which train clinicians to work in underserved communities.

Why do we need such programs?

Higher Education is funded and organized by the US ruling class:– Weill-Cornell Medical School– Charles H. Greenberg Pavilion @ NYH– Belfer Building @ AECOM– Interlocking corporate academic directorships

Medical Students are a very privileged group.

Contextual Factors

Well recognized problem for rural areas

US government has attempted to address through HRSA, NHSC

Literature on financial incentives and specific curricular elements

Efforts going on at the undergraduate level:– High School, College, Post-baccalaureate

Locating Programs

Google Search for websites; Google Scholar for articles

Snow-balling technique (referrals)

HRSA funded programs (1999-2000) to promote Primary Care

Literature Review

Inclusion Criteria– Medical Schools & Residency Programs– Mission to accept minority/working class students

and/or train for underserved communities– Published literature about program outcomes

Exclusion criteria:– High School or College enrichment programs– Rural Programs– Traditionally African American Medical Schools

Interviews (phone/email/website)

How and why program was created

How the program is financed and its cost to students

Educational philosophy & curriculum

Recruitment & retention policies

Evaluation methods of graduates long term success & programmatic success

Relationship to more traditional training programs

Barriers and successes

Medical Schools

Sophie Davis School of Biomedical Engineering (CUNY)

Charles R. Drew Program (UCLA) UC/PRIME programs (5 programs - 1 is rural) A.T. Still University School of Osteopathic

Medicine (SOMA) Baylor College (Texas)

Residency Programs (sample)

Arizona University of Arizona Family & Community Medicine

California UCLA/Harbor Family Medicine Residency UCSF/San Francisco General Hospital: Family &

Community Medicine

Florida University of Miami/Jackson Memorial Family

Medicine & Community Health Miller School of Medicine: Jay Weiss Residency in

Global Health Equity & Internal Medicine. Also at Jackson Memorial

Residency Programs (sample)

Illinois Cook County Internal Medicine Primary Care

Maryland Johns Hopkins Bloomberg School of Public

Health, General Preventive Medicine Residency (PM)

Massachusetts U Mass, Worcester: Family Medicine &

Community Health Lawrence Family Medicine Residency

Residency Programs (sample)

New York Residency Program in Social Medicine (FM,IM,PED)

Washington University of Washington, Tacoma Family Medicine

Justifications offered by programs

US population increasingly diverse

Minority/working class students face growing barriers getting into medical school

Geographical maldistribution of physicians: both urban & rural

Minority and working class populations have worse health care access & outcomes (health disparities)

Structure of Programs

Medical school programs typically associated with traditional MS, but offer enhanced curriculum (ie. disparities, community health)

Training often occurs in community settings, particularly community health centers

Service training sites are in underserved areas

Requirement for research/paper/project/Masters degree

Special mentorship

Educational Philosophy

Emphasis on Primary Care

Work in communities, specifically underserved communities

Work in Community Health Centers

Recruitment/Retention

Pairing with college-level pipeline programs

Trainees expected to share program vision of working in underserved communities

Special mentorship & assistance

Methods of evaluation within programs

Racial/Ethnic/Class composition of trainees (or) graduates

Intention vs. actual practice in underserved communities

Practice in primary care

Traditional academic metrics: board scores, specialization rates; graduates who are faculty or involved in public health administration

Evaluation Techniques

Use of AAMC survey data on where students intend to practice

– Measured at 3 time points: MCAT, entrance and exit to medical school

AMA master file of clinicians to determine practice sites of graduates

HPSA (Health Professional Shortage Areas)

Follow-up surveys of trainees– Such surveys are uncommon and cost money

Evaluation: Charles R. Drew Medical Education Program

Ko M, Edelstein RA, Heslin KC, Rajagopalan S, Wilkerson L, Colburn L, et al. Impact of the University of California, Los Angeles/Charles R. Drew University medical education program on medical students' intentions to practice in underserved areas. Acad Med. 2005 Sep;80(9):803-8.

Outcomes

Programs report high levels of training minority and/or working class physicians

High level of work by graduates in primary care and underserved areas

Successful academic outcomes

Caveats

Those who make it to medical school are the “lucky few.”

Selection bias: Students entering these programs know what they are getting into

What are appropriate comparison groups for these programs?

These programs are all small, almost “boutique” programs

Caveats (Contextual issues)

We are losing this battle now….– Barriers to getting into medical school appear to

have increased since the 1990’s.– Decreasing number of US students choose

primary care.

These programs rely on funding for Primary Care training programs (Title VII)

A mission to serve the underserved does not currently characterize most of US academic medicine (neither does an interest in PC)

Conclusions

Successful programs exist that train clinicians to work in underserved communities.

Shared elements– Mission to serve the underserved (caveat: this

was a selection criteria)– Training in underserved communities.– Community & Primary Care orientation

These findings are similar to those in rural health programs.

Next Steps/Discussion points

How might this project inform our own work?

What are its broader implications for academic medical institutions?– Is the medical school responsible for the

composition of its classes & the future careers of its doctors?

What are the broader implications for US education if professional careers are unavailable to large sections of the population?

Thank You

Contacts:

Matthew Anderson, MD, MSbronxdoc@gmail.com