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Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years a
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Karen Sokal-Gutierrez , Susan L. Ivey , Roxanna M. Garcia & Amin Azzam
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UC Berkeley–UCSF Joint Medical Program, University of California, Berkeley, Berkeley, California, USA b
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Department of Epidemiology, University of California, Berkeley, Berkeley, California, USA Published online: 20 Apr 2015.
To cite this article: Karen Sokal-Gutierrez, Susan L. Ivey, Roxanna M. Garcia & Amin Azzam (2015) Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years, Teaching and Learning in Medicine: An International Journal, 27:2, 189-196, DOI: 10.1080/10401334.2015.1011650 To link to this article: http://dx.doi.org/10.1080/10401334.2015.1011650
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Teaching and Learning in Medicine, 27(2), 189–196 Copyright Ó 2015, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2015.1011650
Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years Karen Sokal-Gutierrez and Susan L. Ivey UC Berkeley–UCSF Joint Medical Program, University of California, Berkeley, Berkeley, California, USA
Roxanna M. Garcia Department of Epidemiology, University of California, Berkeley, Berkeley, California, USA
Amin Azzam
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UC Berkeley–UCSF Joint Medical Program, University of California, Berkeley, Berkeley, California, USA
Problem: Medical educators, clinicians, and health policy experts widely acknowledge the need to increase the diversity of our healthcare workforce and build our capacity to care for medically underserved populations and reduce health disparities. Intervention: The Program in Medical Education for the Urban Underserved (PRIME-US) is part of a family of programs across the University of California (UC) medical schools aiming to recruit and train physicians to care for underserved populations, expand the healthcare workforce to serve diverse populations, and promote health equity. PRIME-US selects medical students from diverse backgrounds who are committed to caring for underserved populations and provides a 5-year curriculum including a summer orientation, a longitudinal seminar series with community engagement and leadership-development activities, preclerkship clinical immersion in an underserved setting, a master’s degree, and a capstone rotation in the final year of medical school. Context: This is a mixed-methods evaluation of the first 4 years of the PRIME-US at the UC Berkeley–UC San Francisco Joint Medical Program (JMP). From 2006 to 2010, focus groups were conducted each year with classes of JMP PRIME-US students, for a total of 11 focus groups; major themes were identified using content analysis. In addition, 4 yearly anonymous, online surveys of all JMP students, faculty and staff were conducted and analyzed. Outcome: Most PRIME-US students came from socioeconomically disadvantaged backgrounds and ethnic backgrounds underrepresented in medicine, and all were committed to caring for underserved populations. The PRIME-US students experienced many program benefits including peer support, professional role models and mentorship, and curricular enrichment activities that developed their knowledge, skills, and sustained commitment to care for underserved populations. Non-PRIME students, faculty, and staff also benefited from participating in PRIME-sponsored seminars and community-based activities. Challenges noted by
Correspondence may be sent to Karen Sokal-Gutierrez, UC Berkeley-UCSF Joint Medical Program, 570 University Hall, MC 1190, Berkeley, CA 94720, USA. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/htlm.
PRIME-US students and non-PRIME students, faculty, and staff included the stress of additional workload, perceived inequities in student educational opportunities, and some negative comments from physicians in other specialties regarding primary care careers. Lessons Learned: Over the first 4 years of the program, PRIME-US students and non-PRIME students, faculty, and staff experienced educational benefits consistent with the intended program goals. Long-term evaluation is needed to examine the participants’ medical careers and impacts on California’s healthcare workforce and patient outcomes. Attention should also be paid to the challenges of implementing new medical education enrichment programs. Keywords
underserved, medical education, PRIME, evaluation, urban
BACKGROUND The racial and ethnic diversity of the U.S. population is increasing dramatically. Since 1970, the proportion of racial and ethnic minorities has more than doubled;1 estimates are that by 2060, “minorities” will compose more than 50% of the U.S. population.2 California is the state with the greatest population diversity, as well as number and percentage of immigrants, particularly from Latin America and Asia. In 2013, California’s population was 38% Hispanic/Latino, 14% Asian, and 7% African American;3 the percentages of Hispanic/ Latino and Asians are predicted to increase over coming decades.4,5 Medical educators, clinicians, and health policy experts widely acknowledge the need for a diverse healthcare workforce with the linguistic and cultural skills to care for our diverse population. To assess healthcare workforce diversity, the terms “underrepresented minorities” (URM) and “underrepresented in medicine” (UIM) were coined.6–8 In 2003, the Association of American Medical Colleges defined UIM as “racial and ethnic groups that are underrepresented in the health professions relative to their numbers in the general
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population,” including Latinos, African Americans, and American Indians.9 From 1978 to 2008, these ethnic groups represented 12% of the U.S. allopathic medical school graduates, substantially below their 28% representation in the general population.10–12 In California, only 5% of physicians are Latino, compared to 38% of the population; only 3% of physicians are African American compared to 7% of the population.8 In addition, the Association of American Medical Colleges UIM definition recommends modifying the “underrepresented” designation based on the changing demographics of the population and the medical profession.9 There is also underrepresentation of health professionals from socioeconomically disadvantaged backgrounds, diverse gender identities and sexual orientations, and those with disabilities, as well as an undersupply of healthcare providers in rural and inner-city areas, and primary care physicians compared with specialists.9,10,13 After 2014, it is expected that physician shortages will be further exacerbated by the expansion of healthcare coverage through the Patient Protection and Affordable Care Act.13 Because ethnic minority populations and other underrepresented groups generally suffer from poorer access to healthcare, improving the capacity of the healthcare workforce to serve these populations remains a major concern for medical education programs.7,14,15 To promote increased diversity in the health professions, “pipeline programs” for high school and college students, and specialized medical education programs have been developed.6,7,14 Medical school programs to promote rural and urban medical workforces have demonstrated success based on careful recruitment of students, and a longitudinal curriculum with didactic and skills-based components.16,17 Historically Black Universities (Morehouse School of Medicine, Meharry Medical College, and Howard University College of Medicine) graduate the highest proportion of primary care physicians, with many graduates practicing in federally underserved areas.11,18,19 Among medical school programs oriented toward the urban underserved, the University of California, Los Angeles (UCLA) Charles R. Drew University Medical Education Program provides 3rd- and 4th-year medical students with clinical experience in low-income areas of Los Angeles and research opportunities in health disparities.20 Program evaluation found that Drew students were 9 times more likely than traditional UCLA students to maintain or increase their intention to work in underserved communities.21 The Sophie Davis/ City University of New York program reported that 25% of graduates were URMs,22 and half of their URM graduates practiced in low-access urban areas in New York State.23 University of Wisconsin School of Medicine and Public Health, Training in Urban Medicine and Public Health program graduates were more likely than their peers to select primary care residency programs serving urban underserved populations.24 Over the past decade, the University of California (UC) launched a system-wide initiative, Program In Medical Education (PRIME), to increase medical student enrollment
by one-third by 2020, increase numbers of physician graduates caring for medically underserved populations, and develop a unique focus at each of the five UC medical campuses.25,26 In 2003, UC Irvine launched PRIME-LC, focusing on the Latino community. In 2006, UC San Francisco (UCSF) School of Medicine and UC Berkeley–UCSF Joint Medical Program (JMP) started the PRIME for the Urban Underserved (PRIMEUS). Subsequently, UC established PRIME programs at UC Davis focused on rural underserved, UCLA focused on health disparities and leadership, and UC San Diego focused on health equity.25–27 PRIME-US at UCSF and JMP is a unified program at two nearby associated medical school sites (see Figure 1). The aims of PRIME-US are to (a) recruit medical students from diverse backgrounds committed to caring for urban underserved populations; (b) provide an enriched medical education experience to prepare these students as leaders in clinical care, health policy, research, and advocacy for urban underserved; (c) increase awareness among JMP and UCSF students about health disparities and underserved populations; and (d) increase the number of medical school graduates working to improve the health of underserved populations. PRIME-US has a common curriculum for UCSF and JMP students, with slight modifications for each school’s schedule, including a summer orientation, a longitudinal seminar series with community engagement and leadership-development activities, preclerkship clinical immersion in an underserved setting, a master’s degree, and a capstone rotation in the final year of medical school (see Table 1). The JMP is a 5-year medical program, based in the UC Berkeley School of Public Health, in which students complete both a master’s degree (M.S.) and medical degree (M.D.). Students spend 3 preclerkship years on the UC Berkeley campus completing a case-based medical curriculum, clinical preceptorships, and master’s courses/research and 2 clerkship years at UCSF. The JMP is a small medical program with 16 students in each year, including four PRIME-US students, per class. The JMP PRIME-US students’ curriculum is integrated as much as possible with the regular JMP curriculum. The
FIG. 1.
PRIME-US program structure.
EVALUATION OF PRIME-US: THE FIRST 4 YEARS
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TABLE 1 Curriculum components of PRIME-US Component
Schedule
Specific Examples
Summer Orientation
1 week before starting medical school
Seminars, Community Engagement, and Leadership Skills
Every 1–2 weeks for first 3 years, and approximately monthly for final 2 years
Preclerkship Clinical Immersion
Every 1–2 weeks for first 3 years
Master’s Degree
First 3 years at JMP
Clerkships and Longitudinal Continuity Experience Capstone Experience
Final 2 years
Personal and professional reflection; Team building; Meeting faculty and student mentors; Health disparities research; Community health assessment; Local underserved populations and resources; Site visits to community clinics and community-based organizations Seminars and Community Engagement: Community law and health advocacy; Incarcerated adult and youth populations; Environmental and social toxic tour; Agricultural worker health; Lobby day in State Capitol; Leadership Skills: Critical reflection; Public speaking; New media skills; Mentoring in medicine; Final presentations Longitudinal clinical preceptorship in community health center or public hospital; Mentorship by clinician; Orientation to clinic structure, community, and resources; Cultural and linguistic competence skills; Community-based service learning project Coursework, original research and thesis related to health of underserved populations Rotations and electives in underserved hospitals and clinics
Other Program Components
1 month rotation in last year of medical school Leadership skills; Community engagement; Advocacy; Health systems; Health policy; Social and behavioral science, and quantitative, qualitative, and translational research; Legacy project 5 years of medical school Faculty mentorship; Student psychosocial support; Student academic support, as needed
Note: The schedule for Joint Medical Program (JMP) PRIME-US students, which involved minor modifications from the UCSF PRIME-US student schedule.
JMP PRIME-US students complete their core medical curriculum with JMP classmates, a longitudinal clinical immersion in a community health center and/or public hospital, and master’s research focused on health issues for underserved populations. In addition, JMP PRIME-US students receive academic credit for the PRIME summer orientation and seminar series. To extend the benefits of PRIME to non-PRIME students and the entire JMP community, monthly Underserved Seminars were offered on a variety of topics including Public Health Insurance Coverage, Health Literacy, Integrative Medicine, and Prison Health. We report here the experience of the first 4 years of the PRIME-US program at the JMP, from 2006 to 2010. This is an evaluation of the experiences of the 16 JMP PRIME-US
medical students during their preclerkship medical student (MS 1–3) and first clerkship (MS-4) years; and the impact of PRIME-US on the entire JMP program including non-PRIME students, faculty, and staff.
METHODS We chose a mixed-method evaluation strategy to maximize the programmatic value of the results.
Assessment of JMP PRIME-US Student Experiences Quantitative data on JMP PRIME-US students’ demographic backgrounds were abstracted from their medical
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school applications; medical residency match choices by student report. Focus groups and qualitative analysis were used to assess the experiences of students enrolled in JMP PRIME-US. In Year 1, we conducted two focus groups with the four PRIMEUS students; in subsequent years, each class of four students participated in one focus group annually, for a total of 11 groups. Due to limited resources, it was possible to do the indepth evaluation of program implementation with focus groups and surveys for only the first 4 years of the program, from 2006 to 2010. We developed a structured focus group guide, and trained 5th-year JMP-non-PRIME-US students as facilitators. Questions were updated for MS-4 students to capture the effects of PRIME-US on their transition to clerkships at UCSF. Focus groups were audio-recorded, transcribed verbatim, reviewed by the facilitator, and deidentified. Initial analysis used a grounded theory approach, with one faculty member (SI) and the focus group facilitator coding separately. The two coders then compared their codes and developed a codebook for ongoing coding. New codes were allowed to arise from the data with unique codes added each year. Although the faculty member remained the same over the 4year period, facilitators were different each year, and the codebook promoted coding consistency. A final content analysis across the 4 years (KSG) summarized major themes into domains and highlighted strengths and challenges to guide program improvement.
Assessment of the Impact of PRIME-US on the Entire JMP Community We used quantitative and qualitative methods to assess the impact of the PRIME-US program on the entire JMP, including non-PRIME students, faculty, and staff. An annual, anonymous, online survey was sent to all JMP faculty, staff, and students. Each year, we used the same survey instrument; the survey was open from January to April. The survey contained closed-ended questions regarding the respondents’ affiliation with the JMP and participation in PRIME-US activities. Openended questions asked how the presence of the PRIME program enhanced and/or hindered respondents’ educational/ work experience and solicited suggestions for improvement. Several authors (AA, KSG, SI) coded open-ended responses, which we compared for intercoder consistency, aggregated into themes, and quantified. New codes were allowed to emerge in subsequent academic years.
RESULTS The results of the evaluation are organized according to the four program aims:
1. Recruit Medical Students From Diverse Backgrounds Committed to Caring for Urban Underserved Populations PRIME-US applicants were recruited through outreach activities and a supplemental admissions process with a specialized committee review of student backgrounds, essays, and interviews. Nearly half of matriculating JMP students had applied to PRIME-US, whereas only one-fourth could be accepted into the program. Only those applicants who demonstrated a deep commitment to caring for urban underserved populations were admitted to PRIME-US. Most came from socioeconomically disadvantaged backgrounds (75%) and ethnic backgrounds underrepresented in medicine (Latino 44%, African American 19%). Students also represented diverse Asian ethnicities with cultural and language skills; lesbian, gay, bisexual, and transgender; and rural backgrounds. Many non-PRIME students were also from UIM backgrounds and had expressed commitment to underserved populations.
2. Provide an Enriched Medical Education Experience to Prepare These Students as Leaders in Clinical Care, Health Policy, Research, and Advocacy for Urban Underserved The Preclerkship Years Preclerkship PRIME-US students reported their experiences in three general domains: relationships with fellow students; relationships with physician faculty and clinical preceptors; and curricular enrichment activities including seminars, community-based activities, and longitudinal clinical preceptorships. Relationships with fellow medical students. The JMP PRIME-US students commented most frequently, and generally positively, on their relationships with fellow medical students. Beginning in the PRIME-US summer orientation week, students cited how discussions and community-based activities helped them develop intimate and supportive relationships with PRIME-US peers. Students shared similar values and career goals, and many explained that these relationships provided critical support to sustain them through the stresses of medical school. For example, a 1st-year PRIME-US student stated: I think it is so important that as medical school students pledged to help the underserved in medicine, we have each other to rely on. We can look to one another during challenging and hard times and be supported.
Although most of the comments about peer relationships were positive, some students expressed concerns about inequities with their non-PRIME classmates, some of whom had applied to and not been accepted to the program:
EVALUATION OF PRIME-US: THE FIRST 4 YEARS Sometimes I feel funny talking about PRIME in front of our classmates. I feel like I don’t want people’s feelings to be hurt. (1st-year PRIME-US student)
Relationships with physician faculty and clinical preceptors. Students also discussed how PRIME-US activities facilitated the development of close relationships with physician faculty members and preceptors. Most students described the positive aspects of gaining physician role models and mentors who were working successfully in underserved settings:
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One of the things most important to me . . . is role models . . . just being able to see people that are in primary care that have been doing it for so many years, and they’re not completely beaten down . . . even though they’re working against all of these amazingly huge challenges. (2nd-year PRIME-US student)
Some students shared concerns that, due to the lowresource settings in which they practiced medicine, their clinical preceptors were very busy and stressed, sometimes impairing their willingness and ability to devote time to teaching: I think a lot of it just hinges on your preceptor. . . . I’m lucky to have a really good educator, and I think some people end up with ones who really aren’t as into it, which is too bad. (2nd-year PRIME-US student)
Curricular enrichment experiences including seminars, community-based activities, and longitudinal clinical preceptorships. Many students commented that PRIME-US activities helped them develop knowledge and skills that prepared them to work with underserved populations. They noted that community-based experiences were a welcome opportunity to apply what they learned in the classroom and helped maintain commitment to their career goals: It’s been really cool to take histories and listen to people’s stories and have a greater understanding of the challenges they face, what actually ends up making ‘the underserved.’ (2nd-year PRIME-US student)
Many students commented that the 2-year longitudinal clinical preceptorship provided a valuable immersion in an underserved setting and community, facilitating deeper appreciation of the context of healthcare in that community. However, some commented that it limited their ability to experience a variety of healthcare settings and communities: For the first two years, I was at a really amazing outpatient clinic with a really overextended preceptor. . . . I was very grateful to have the opportunity to switch to a different setting, also just to get to see what in-patient medicine is like. (3rd-year PRIME-US student)
Although most students valued the enrichment experiences that PRIME-US provided, many commented on the extra
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workload, particularly given the time pressures of their medical curriculum and master’s degree courses and research. Students cited the greatest workload challenges during their first semester, as they adjusted to medical school; and during 3rd year, as they completed their master’s thesis, studied for the boards, and prepared for clinical clerkships: It’s really great to get all of these exposures, but sometimes it can also be really challenging to do these additional things outside of school, and being a med student, and being in our Master’s [program]. (2nd-year PRIME-US student)
The Clerkship Years During their clinical clerkships, the JMP PRIME-US students reported that they continued to experience the benefits and challenges discussed in previous years. A new theme that emerged was the feedback that they received from attending physicians and residents on clinical rotations. The students cited positive feedback about their strong clinical preparation to care for underserved populations but also some criticism of their career choices in primary care or family medicine. Clinical preparation to care for underserved populations. The PRIME-US students reported finding that they possessed greater knowledge about health disparities than their peers and confidence to advocate for underserved populations in clinical settings. Several students noted that non-PRIME medical students, residents, and attendings positively affirmed their ability and willingness to care for patients from underserved populations: Talking to residents . . . who had gone to other schools where there wasn’t as much of an emphasis or . . . an opportunity to work in a county hospital. . . . ‘Wow, you’re really getting a different education than what I got.’ (4th-year PRIME-US student)
Criticism of career choices in primary care and family medicine. During their 1st year of clerkships, PRIME-US students described trying to learn about all medical specialties while maintaining their commitment to underserved populations. Although PRIME-US encourages students to pursue whatever medical specialty may interest them, many PRIMEUS students are committed to careers in primary care and family medicine. Some students mentioned that, on various rotations, attendings and residents made derogatory comments about careers in primary care, which they felt uncomfortable having to defend: I feel like working with underserved, it’s not like people are really going to challenge you on that issue. But family medicine— throughout the year, I got a series of lectures. . . . I just decided I’m going to sit here and nod. (4th-year PRIME-US student)
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3. Increase Awareness Among JMP and UCSF Students About Health Disparities and Underserved Populations We gathered comments about the impact of PRIME-US on the JMP from the survey of all JMP students, faculty, and staff and the PRIME-US student focus groups. From both sources, mostly positive comments emerged, primarily regarding the value of enriching the medical school curriculum with health issues for underserved populations. However, challenges were also identified, particularly the additional workload involved, and concerns about unequal opportunities for students to participate in the program.
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Survey of Entire JMP Response rates to the four annual surveys ranged from 53% to 77% among approximately 70 JMP faculty, staff, and students. For open-ended questions, responses could be coded into more than one theme. Consequently, we could not do direct numerical comparisons of the raw responses across years. Instead, we calculated individual themes as percentages of responses within years, thereby allowing for comparison of theme percentages across academic years. The most common positive impact cited was that PRIMEUS increased the general program-wide support for caring for underserved populations, and specifically increased the curricular opportunities through seminars, community activities, and clinical preceptorships with underserved populations for all students. The most common negative impact cited was the increased workload related to the new program and activities.
PRIME-US Student Focus Group Comments Students in the pilot year of PRIME-US expressed enthusiasm about helping to build a new program, but they were also concerned about programmatic issues such as defining PRIME’s mission and policies, clarifying how the program would function within each medical school and across campuses, and securing adequate funding and staff/faculty support. Most PRIME-US students experienced substantial benefits from program participation and strongly felt that supplementary educational and service opportunities with urban underserved populations should be extended to the entire JMP community. The JMP is a small medical school where students work closely together in a collaborative small-group process. Given that PRIME-US students are philosophically oriented toward recognizing and eliminating disparities, and promoting social justice and “equity,” they felt uncomfortable with inequities in medical education opportunities. For example, one 2nd-year PRIME-US student stated: Keeping those [underserved seminars] open to everyone in the JMP . . . it’s hard to get busy people pinned down to a time, but that’s a really important piece to keep going.
4. Increase the Number of UCSF Medical School Graduates Working to Improve the Health of Underserved Populations During the focus group discussions and subsequent followup contact with PRIME-US graduates, all students expressed their continued commitment to work with underserved populations. Of the 16 entering JMP PRIME-US students from 2006 to 2010, 14 have entered medical residency programs, one has deferred residency selection, and one left medicine for another health career. There was a diverse representation of specialties, with the majority choosing primary care fields of family medicine (38%), internal medicine (12%), and pediatrics (12%); followed by emergency medicine (12%), psychiatry (7%), and ophthalmology (7%). Many non-PRIME students also chose to enter primary care specialties. DISCUSSION This was a mixed-methods study of the implementation of a new medical education program at the UC Berkeley–UCSF Joint Medical Program—PRIME-US—designed to recruit and train medical students committed to caring for underserved populations. This study demonstrated short-term effects of PRIME-US that were generally positive and consistent with the original program goals. The PRIME-US students identified many benefits including peer support, professional role models, mentorship, and curriculum enrichment activities that developed their knowledge and skills to care for underserved populations. Non-PRIME JMP students, faculty, and staff also benefited from participating in PRIME-sponsored seminars and community-based activities, noting that PRIME-US increased program-wide attention to issues for medically underserved populations. In addition, respondents noted implementation challenges including additional workload, limitations in clinical preceptorships, disparities among student educational opportunities, and some negative comments from physicians in other specialties about primary care careers. This evaluation shares similar findings with other evaluations of medical school programs for underserved populations, including the value of recruiting diverse and committed students; the benefits of curriculum enhancement, clinical experiences, and mentorship; the ability to sustain the commitment of graduates to underserved medicine; and the need to address disincentives for graduates entering primary care careers.16,20– 22,24,28,29 In addition, by conducting a “360-degree” process evaluation of program participants and nonparticipants, this study identifies additional challenges to program implementation such as increased workload, limited resources, and concerns about inequitable opportunities for students, which are important to address for successful program implementation. In particular, because the program goals include increasing the awareness and willingness of all medical students to care for underserved populations, it is critical to extend some program components to all students.
EVALUATION OF PRIME-US: THE FIRST 4 YEARS
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Each year, the results of the evaluation were reported back to students, faculty, and staff, and discussion was encouraged around priorities for program improvement. Based on the feedback, measures were taken to enhance the program. For PRIME-US students, improvements included clarifying the program mission, converting the preclerkship preceptorship to 2-year outpatient and 1-year hospital setting, and increasing student grant and scholarship opportunities. For non-PRIME students, improvements included increasing the availability of clinical preceptorships in underserved settings and extending opportunities to participate in underserved seminars and community-based activities.
CONCLUSION Longitudinal evaluation of elective medical school curricular additions can help demonstrate “value added,” adherence to original program goals, and ultimately long-term impacts. Over the first 4 years of PRIME-US, our medical school community experienced educational benefits consistent with the intended program goals to provide support, knowledge, and skills to care for underserved populations. The evaluation also demonstrated that schools should address the challenges of implementing new medical education enrichment programs— particularly the extra workload, the potential for inequities among students, and the need for consistent institutional support. Given that JMP and PRIME are small medical school programs, the results of this evaluation may not be generalizable to larger programs. Future studies should assess the longer term impact of the PRIME programs on healthcare workforce diversity and the supply of physicians caring for underserved populations.
ACKNOWLEDGMENTS We recognize and thank the following: Jennifer Wilson, Tami Rowen, and Joanna Eveland, who facilitated the focus groups and assisted in the analysis; Elisabeth Wilson and Aisha Queen Johnson who provided invaluable programmatic guidance and support; the entire JMP student, faculty, and staff community who shaped, experienced, and helped evaluate the curricular innovation; and the community health professionals and patients who contributed immeasurably to our medical students’ education. The UC Berkeley Committee for Protection of Human Subjects deemed this study exempt. Approval to conduct this evaluation was granted on October 24, 2006 (Reference ID: CPHS Protocol #2006-10-58).
FUNDING We thank the University of California Office of the President, and Anthem Blue Cross of California, who provided funding for PRIME-US at JMP.
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REFERENCES 1. Hobbs F, Stoops N. Demographic trends in the 20th century: Census 2000 special reports (Series CENSR-4). Washington, DC: U.S. Census Bureau, US Government Printing Office, 2002. Available at: http://www.census. gov/prod/2002pubs/censr-4.pdf. Accessed June 4, 2013. 2. 2012 National Population Projections: Summary tables. Available at: http://www.census.gov/population/projections/data/national/2012/sum marytables.html. Accessed June 6, 2013. 3. United States Census Bureau, State and County QuickFacts: California. Available at: http://quickfacts.census.gov/qfd/states/06000.html. Accessed September 4, 2014. 4. Public Policy Institute of California: California’s Population. Available at: http://www.ppic.org/main/publication_show.asp?iD259. Accessed September 4, 2014. 5. State of California, Department of Finance. Report P-1 (Race): State and county population projections by race/ethnicity, 2010-2060. Sacramento, CA, 2013. 6. Smedley BD, Butler AS, Bristow LR (Eds.). In the nation’s compelling interest: Ensuring diversity in the health-care workforce. Washington, DC: The National Academies Press, 2004. 7. Sullivan LW. Missing persons: Minorities in the health professions, A report of the Sullivan Commission on diversity in the healthcare workforce. Washington, DC: Sullivan Commission, September 2004. Available at: http://health-equity.pitt.edu/40/1/Sullivan_Final_Report_000.pdf. Accessed June 6, 2013. 8. Paxton C. California healthcare almanac: California physician facts and figures. 2010 ed. Oakland: California Healthcare Foundation, July 2010. Available at: http://www.chcf.org/~/media/ MEDIA%20LIBRARY%20Files/PDF/C/PDF%20CaliforniaPhysician FactsFigures2010.pdf. Accessed June 6, 2013. 9. Association of American Medical Colleges: Underrepresented in Medicine Definition. Available at: https://www.aamc.org/initiatives/urm/. Accessed June 6, 2013. 10. Smart DR. Physician characteristics and distribution in the U.S. 2012 (2013 ed.). Chicago, IL: American Medical Association, 2013. 11. Castillo-Page L. Diversity in the physician workforce: Facts & figures 2010 (2010 ed.). Washington, DC: Association of American Medical Colleges, 2010. Available at: https://members.aamc.org/eweb/upload/ Diversity%20in%20the%20Physician%20Workforce%20Facts%20and %20Figures%202010.pdf. Accessed September 4, 2014. 12. Castillo-Page L. Diversity in medical education: Facts and figures 2012. Washington, DC: Association of American Medical Colleges, 2012. Available at: https://members.aamc.org/eweb/upload/ Diversity%20in%20Medical%20Education_Facts%20and%20Figures %202012.pdf. Accessed September 4, 2014. 13. U.S. Department of Health and Human Services; Health Resources and Services Administration, Bureau of Health Professions. The physician workforce: Projections and research into current issues affecting supply and demand. Washington, DC: U.S. Department of Health and Human Services, December 2008. Available at: http://bhpr.hrsa.gov/healthwork force/reports/physwfissues.pdf. Accessed June 5, 2013. 14. Grumbach K, Mendoza R. Disparities in human resources: Addressing the lack of diversity in the health professions. Health Affairs 2008;2:413–22. 15. U.S. Department of Health and Human Services. HHS Action Plan to Reduce Racial and Ethnic Disparities: A nation free of disparities in health and health care. Washington, DC: U.S. Department of Health and Human Services, 2011. Available at: http://minorityhealth.hhs. gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf. Accessed September 5, 2014. 16. Glasser M, Hunsaker M, Sweet K, MacDowell M, Meurer M. A comprehensive medical education program response to rural primary care needs. Academic Medicine 2008;10:952–61. 17. Schwarz MR. The WAMI Program: 25 years later. Medical Teacher. 2004;3:211–4.
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18. Keith SN, Bell RM, Williams AP. Affirmative action in medical education and its effect on Howard and Meharry: A study of the class of 1975. Journal of the National Medical Association 1988;2:153–8. 19. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Annals of Internal Medicine 2010;12:804–11. 20. Ko M, Heslin KC, Edelstein RA, Grumbach K. The role of medical education in reducing health care disparities: The first ten years of the UCLA/Drew Medical Education Program. Journal of General Internal Medicine 2007;5:625–31. 21. 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. Academic Medicine 2005;9:803–8. 22. Roman SA Jr, McGanney ML. The Sophie Davis School of Biomedical Education: The first 20 years of a unique BS-MD program. Academic Medicine 1994;3:224–30.
23. Cregler LL, McGanney ML, Roman SA, Kagan DV. Refining a method of identifying CUNY Medical School graduates practicing in underserved areas. Academic Medicine 1997;9:794–7. 24. Haq C, Stearns M, Brill J, Crouse B, Foertsch J, Knox K, et al. Training in Urban Medicine and Public Health: TRIUMPH. Academic Medicine 2013;3:352–63. 25. Nation CL, Gerstenberger A, Bullard D. Preparing for change: The plan, the promise, and the parachute. Academic Medicine 2007;12:1139–44. 26. Drake MV. The need for diversity in medical education: Barriers to be broken. Archives of Ophthamology 2009;10:1387–8. 27. Manetta A, Stephens F, Rea J, Vega C. Addressing health care needs of the Latino community: One medical school’s approach. Academic Medicine 2007;10:1145–51. 28. Senf JH, Campos-Outcalt D, Kutob R. Factors related to choice of family medicine: A reassessment and literature review. The Journal of the American Board of Family Practice 2003;6:502–14. 29. Bodenheimer T, Pham H. Primary care: Current problems and proposed solutions. Health Affairs 2010;5:799–805.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years a
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Karen Sokal-Gutierrez , Susan L. Ivey , Roxanna M. Garcia & Amin Azzam
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UC Berkeley–UCSF Joint Medical Program, University of California, Berkeley, Berkeley, California, USA b
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Department of Epidemiology, University of California, Berkeley, Berkeley, California, USA Published online: 20 Apr 2015.
To cite this article: Karen Sokal-Gutierrez, Susan L. Ivey, Roxanna M. Garcia & Amin Azzam (2015) Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years, Teaching and Learning in Medicine: An International Journal, 27:2, 189-196, DOI: 10.1080/10401334.2015.1011650 To link to this article: http://dx.doi.org/10.1080/10401334.2015.1011650
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Teaching and Learning in Medicine, 27(2), 189–196 Copyright Ó 2015, Taylor & Francis Group, LLC ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2015.1011650
Evaluation of the Program in Medical Education for the Urban Underserved (PRIME-US) at the UC Berkeley–UCSF Joint Medical Program (JMP): The First 4 Years Karen Sokal-Gutierrez and Susan L. Ivey UC Berkeley–UCSF Joint Medical Program, University of California, Berkeley, Berkeley, California, USA
Roxanna M. Garcia Department of Epidemiology, University of California, Berkeley, Berkeley, California, USA
Amin Azzam
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UC Berkeley–UCSF Joint Medical Program, University of California, Berkeley, Berkeley, California, USA
Problem: Medical educators, clinicians, and health policy experts widely acknowledge the need to increase the diversity of our healthcare workforce and build our capacity to care for medically underserved populations and reduce health disparities. Intervention: The Program in Medical Education for the Urban Underserved (PRIME-US) is part of a family of programs across the University of California (UC) medical schools aiming to recruit and train physicians to care for underserved populations, expand the healthcare workforce to serve diverse populations, and promote health equity. PRIME-US selects medical students from diverse backgrounds who are committed to caring for underserved populations and provides a 5-year curriculum including a summer orientation, a longitudinal seminar series with community engagement and leadership-development activities, preclerkship clinical immersion in an underserved setting, a master’s degree, and a capstone rotation in the final year of medical school. Context: This is a mixed-methods evaluation of the first 4 years of the PRIME-US at the UC Berkeley–UC San Francisco Joint Medical Program (JMP). From 2006 to 2010, focus groups were conducted each year with classes of JMP PRIME-US students, for a total of 11 focus groups; major themes were identified using content analysis. In addition, 4 yearly anonymous, online surveys of all JMP students, faculty and staff were conducted and analyzed. Outcome: Most PRIME-US students came from socioeconomically disadvantaged backgrounds and ethnic backgrounds underrepresented in medicine, and all were committed to caring for underserved populations. The PRIME-US students experienced many program benefits including peer support, professional role models and mentorship, and curricular enrichment activities that developed their knowledge, skills, and sustained commitment to care for underserved populations. Non-PRIME students, faculty, and staff also benefited from participating in PRIME-sponsored seminars and community-based activities. Challenges noted by
Correspondence may be sent to Karen Sokal-Gutierrez, UC Berkeley-UCSF Joint Medical Program, 570 University Hall, MC 1190, Berkeley, CA 94720, USA. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/htlm.
PRIME-US students and non-PRIME students, faculty, and staff included the stress of additional workload, perceived inequities in student educational opportunities, and some negative comments from physicians in other specialties regarding primary care careers. Lessons Learned: Over the first 4 years of the program, PRIME-US students and non-PRIME students, faculty, and staff experienced educational benefits consistent with the intended program goals. Long-term evaluation is needed to examine the participants’ medical careers and impacts on California’s healthcare workforce and patient outcomes. Attention should also be paid to the challenges of implementing new medical education enrichment programs. Keywords
underserved, medical education, PRIME, evaluation, urban
BACKGROUND The racial and ethnic diversity of the U.S. population is increasing dramatically. Since 1970, the proportion of racial and ethnic minorities has more than doubled;1 estimates are that by 2060, “minorities” will compose more than 50% of the U.S. population.2 California is the state with the greatest population diversity, as well as number and percentage of immigrants, particularly from Latin America and Asia. In 2013, California’s population was 38% Hispanic/Latino, 14% Asian, and 7% African American;3 the percentages of Hispanic/ Latino and Asians are predicted to increase over coming decades.4,5 Medical educators, clinicians, and health policy experts widely acknowledge the need for a diverse healthcare workforce with the linguistic and cultural skills to care for our diverse population. To assess healthcare workforce diversity, the terms “underrepresented minorities” (URM) and “underrepresented in medicine” (UIM) were coined.6–8 In 2003, the Association of American Medical Colleges defined UIM as “racial and ethnic groups that are underrepresented in the health professions relative to their numbers in the general
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population,” including Latinos, African Americans, and American Indians.9 From 1978 to 2008, these ethnic groups represented 12% of the U.S. allopathic medical school graduates, substantially below their 28% representation in the general population.10–12 In California, only 5% of physicians are Latino, compared to 38% of the population; only 3% of physicians are African American compared to 7% of the population.8 In addition, the Association of American Medical Colleges UIM definition recommends modifying the “underrepresented” designation based on the changing demographics of the population and the medical profession.9 There is also underrepresentation of health professionals from socioeconomically disadvantaged backgrounds, diverse gender identities and sexual orientations, and those with disabilities, as well as an undersupply of healthcare providers in rural and inner-city areas, and primary care physicians compared with specialists.9,10,13 After 2014, it is expected that physician shortages will be further exacerbated by the expansion of healthcare coverage through the Patient Protection and Affordable Care Act.13 Because ethnic minority populations and other underrepresented groups generally suffer from poorer access to healthcare, improving the capacity of the healthcare workforce to serve these populations remains a major concern for medical education programs.7,14,15 To promote increased diversity in the health professions, “pipeline programs” for high school and college students, and specialized medical education programs have been developed.6,7,14 Medical school programs to promote rural and urban medical workforces have demonstrated success based on careful recruitment of students, and a longitudinal curriculum with didactic and skills-based components.16,17 Historically Black Universities (Morehouse School of Medicine, Meharry Medical College, and Howard University College of Medicine) graduate the highest proportion of primary care physicians, with many graduates practicing in federally underserved areas.11,18,19 Among medical school programs oriented toward the urban underserved, the University of California, Los Angeles (UCLA) Charles R. Drew University Medical Education Program provides 3rd- and 4th-year medical students with clinical experience in low-income areas of Los Angeles and research opportunities in health disparities.20 Program evaluation found that Drew students were 9 times more likely than traditional UCLA students to maintain or increase their intention to work in underserved communities.21 The Sophie Davis/ City University of New York program reported that 25% of graduates were URMs,22 and half of their URM graduates practiced in low-access urban areas in New York State.23 University of Wisconsin School of Medicine and Public Health, Training in Urban Medicine and Public Health program graduates were more likely than their peers to select primary care residency programs serving urban underserved populations.24 Over the past decade, the University of California (UC) launched a system-wide initiative, Program In Medical Education (PRIME), to increase medical student enrollment
by one-third by 2020, increase numbers of physician graduates caring for medically underserved populations, and develop a unique focus at each of the five UC medical campuses.25,26 In 2003, UC Irvine launched PRIME-LC, focusing on the Latino community. In 2006, UC San Francisco (UCSF) School of Medicine and UC Berkeley–UCSF Joint Medical Program (JMP) started the PRIME for the Urban Underserved (PRIMEUS). Subsequently, UC established PRIME programs at UC Davis focused on rural underserved, UCLA focused on health disparities and leadership, and UC San Diego focused on health equity.25–27 PRIME-US at UCSF and JMP is a unified program at two nearby associated medical school sites (see Figure 1). The aims of PRIME-US are to (a) recruit medical students from diverse backgrounds committed to caring for urban underserved populations; (b) provide an enriched medical education experience to prepare these students as leaders in clinical care, health policy, research, and advocacy for urban underserved; (c) increase awareness among JMP and UCSF students about health disparities and underserved populations; and (d) increase the number of medical school graduates working to improve the health of underserved populations. PRIME-US has a common curriculum for UCSF and JMP students, with slight modifications for each school’s schedule, including a summer orientation, a longitudinal seminar series with community engagement and leadership-development activities, preclerkship clinical immersion in an underserved setting, a master’s degree, and a capstone rotation in the final year of medical school (see Table 1). The JMP is a 5-year medical program, based in the UC Berkeley School of Public Health, in which students complete both a master’s degree (M.S.) and medical degree (M.D.). Students spend 3 preclerkship years on the UC Berkeley campus completing a case-based medical curriculum, clinical preceptorships, and master’s courses/research and 2 clerkship years at UCSF. The JMP is a small medical program with 16 students in each year, including four PRIME-US students, per class. The JMP PRIME-US students’ curriculum is integrated as much as possible with the regular JMP curriculum. The
FIG. 1.
PRIME-US program structure.
EVALUATION OF PRIME-US: THE FIRST 4 YEARS
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TABLE 1 Curriculum components of PRIME-US Component
Schedule
Specific Examples
Summer Orientation
1 week before starting medical school
Seminars, Community Engagement, and Leadership Skills
Every 1–2 weeks for first 3 years, and approximately monthly for final 2 years
Preclerkship Clinical Immersion
Every 1–2 weeks for first 3 years
Master’s Degree
First 3 years at JMP
Clerkships and Longitudinal Continuity Experience Capstone Experience
Final 2 years
Personal and professional reflection; Team building; Meeting faculty and student mentors; Health disparities research; Community health assessment; Local underserved populations and resources; Site visits to community clinics and community-based organizations Seminars and Community Engagement: Community law and health advocacy; Incarcerated adult and youth populations; Environmental and social toxic tour; Agricultural worker health; Lobby day in State Capitol; Leadership Skills: Critical reflection; Public speaking; New media skills; Mentoring in medicine; Final presentations Longitudinal clinical preceptorship in community health center or public hospital; Mentorship by clinician; Orientation to clinic structure, community, and resources; Cultural and linguistic competence skills; Community-based service learning project Coursework, original research and thesis related to health of underserved populations Rotations and electives in underserved hospitals and clinics
Other Program Components
1 month rotation in last year of medical school Leadership skills; Community engagement; Advocacy; Health systems; Health policy; Social and behavioral science, and quantitative, qualitative, and translational research; Legacy project 5 years of medical school Faculty mentorship; Student psychosocial support; Student academic support, as needed
Note: The schedule for Joint Medical Program (JMP) PRIME-US students, which involved minor modifications from the UCSF PRIME-US student schedule.
JMP PRIME-US students complete their core medical curriculum with JMP classmates, a longitudinal clinical immersion in a community health center and/or public hospital, and master’s research focused on health issues for underserved populations. In addition, JMP PRIME-US students receive academic credit for the PRIME summer orientation and seminar series. To extend the benefits of PRIME to non-PRIME students and the entire JMP community, monthly Underserved Seminars were offered on a variety of topics including Public Health Insurance Coverage, Health Literacy, Integrative Medicine, and Prison Health. We report here the experience of the first 4 years of the PRIME-US program at the JMP, from 2006 to 2010. This is an evaluation of the experiences of the 16 JMP PRIME-US
medical students during their preclerkship medical student (MS 1–3) and first clerkship (MS-4) years; and the impact of PRIME-US on the entire JMP program including non-PRIME students, faculty, and staff.
METHODS We chose a mixed-method evaluation strategy to maximize the programmatic value of the results.
Assessment of JMP PRIME-US Student Experiences Quantitative data on JMP PRIME-US students’ demographic backgrounds were abstracted from their medical
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school applications; medical residency match choices by student report. Focus groups and qualitative analysis were used to assess the experiences of students enrolled in JMP PRIME-US. In Year 1, we conducted two focus groups with the four PRIMEUS students; in subsequent years, each class of four students participated in one focus group annually, for a total of 11 groups. Due to limited resources, it was possible to do the indepth evaluation of program implementation with focus groups and surveys for only the first 4 years of the program, from 2006 to 2010. We developed a structured focus group guide, and trained 5th-year JMP-non-PRIME-US students as facilitators. Questions were updated for MS-4 students to capture the effects of PRIME-US on their transition to clerkships at UCSF. Focus groups were audio-recorded, transcribed verbatim, reviewed by the facilitator, and deidentified. Initial analysis used a grounded theory approach, with one faculty member (SI) and the focus group facilitator coding separately. The two coders then compared their codes and developed a codebook for ongoing coding. New codes were allowed to arise from the data with unique codes added each year. Although the faculty member remained the same over the 4year period, facilitators were different each year, and the codebook promoted coding consistency. A final content analysis across the 4 years (KSG) summarized major themes into domains and highlighted strengths and challenges to guide program improvement.
Assessment of the Impact of PRIME-US on the Entire JMP Community We used quantitative and qualitative methods to assess the impact of the PRIME-US program on the entire JMP, including non-PRIME students, faculty, and staff. An annual, anonymous, online survey was sent to all JMP faculty, staff, and students. Each year, we used the same survey instrument; the survey was open from January to April. The survey contained closed-ended questions regarding the respondents’ affiliation with the JMP and participation in PRIME-US activities. Openended questions asked how the presence of the PRIME program enhanced and/or hindered respondents’ educational/ work experience and solicited suggestions for improvement. Several authors (AA, KSG, SI) coded open-ended responses, which we compared for intercoder consistency, aggregated into themes, and quantified. New codes were allowed to emerge in subsequent academic years.
RESULTS The results of the evaluation are organized according to the four program aims:
1. Recruit Medical Students From Diverse Backgrounds Committed to Caring for Urban Underserved Populations PRIME-US applicants were recruited through outreach activities and a supplemental admissions process with a specialized committee review of student backgrounds, essays, and interviews. Nearly half of matriculating JMP students had applied to PRIME-US, whereas only one-fourth could be accepted into the program. Only those applicants who demonstrated a deep commitment to caring for urban underserved populations were admitted to PRIME-US. Most came from socioeconomically disadvantaged backgrounds (75%) and ethnic backgrounds underrepresented in medicine (Latino 44%, African American 19%). Students also represented diverse Asian ethnicities with cultural and language skills; lesbian, gay, bisexual, and transgender; and rural backgrounds. Many non-PRIME students were also from UIM backgrounds and had expressed commitment to underserved populations.
2. Provide an Enriched Medical Education Experience to Prepare These Students as Leaders in Clinical Care, Health Policy, Research, and Advocacy for Urban Underserved The Preclerkship Years Preclerkship PRIME-US students reported their experiences in three general domains: relationships with fellow students; relationships with physician faculty and clinical preceptors; and curricular enrichment activities including seminars, community-based activities, and longitudinal clinical preceptorships. Relationships with fellow medical students. The JMP PRIME-US students commented most frequently, and generally positively, on their relationships with fellow medical students. Beginning in the PRIME-US summer orientation week, students cited how discussions and community-based activities helped them develop intimate and supportive relationships with PRIME-US peers. Students shared similar values and career goals, and many explained that these relationships provided critical support to sustain them through the stresses of medical school. For example, a 1st-year PRIME-US student stated: I think it is so important that as medical school students pledged to help the underserved in medicine, we have each other to rely on. We can look to one another during challenging and hard times and be supported.
Although most of the comments about peer relationships were positive, some students expressed concerns about inequities with their non-PRIME classmates, some of whom had applied to and not been accepted to the program:
EVALUATION OF PRIME-US: THE FIRST 4 YEARS Sometimes I feel funny talking about PRIME in front of our classmates. I feel like I don’t want people’s feelings to be hurt. (1st-year PRIME-US student)
Relationships with physician faculty and clinical preceptors. Students also discussed how PRIME-US activities facilitated the development of close relationships with physician faculty members and preceptors. Most students described the positive aspects of gaining physician role models and mentors who were working successfully in underserved settings:
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One of the things most important to me . . . is role models . . . just being able to see people that are in primary care that have been doing it for so many years, and they’re not completely beaten down . . . even though they’re working against all of these amazingly huge challenges. (2nd-year PRIME-US student)
Some students shared concerns that, due to the lowresource settings in which they practiced medicine, their clinical preceptors were very busy and stressed, sometimes impairing their willingness and ability to devote time to teaching: I think a lot of it just hinges on your preceptor. . . . I’m lucky to have a really good educator, and I think some people end up with ones who really aren’t as into it, which is too bad. (2nd-year PRIME-US student)
Curricular enrichment experiences including seminars, community-based activities, and longitudinal clinical preceptorships. Many students commented that PRIME-US activities helped them develop knowledge and skills that prepared them to work with underserved populations. They noted that community-based experiences were a welcome opportunity to apply what they learned in the classroom and helped maintain commitment to their career goals: It’s been really cool to take histories and listen to people’s stories and have a greater understanding of the challenges they face, what actually ends up making ‘the underserved.’ (2nd-year PRIME-US student)
Many students commented that the 2-year longitudinal clinical preceptorship provided a valuable immersion in an underserved setting and community, facilitating deeper appreciation of the context of healthcare in that community. However, some commented that it limited their ability to experience a variety of healthcare settings and communities: For the first two years, I was at a really amazing outpatient clinic with a really overextended preceptor. . . . I was very grateful to have the opportunity to switch to a different setting, also just to get to see what in-patient medicine is like. (3rd-year PRIME-US student)
Although most students valued the enrichment experiences that PRIME-US provided, many commented on the extra
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workload, particularly given the time pressures of their medical curriculum and master’s degree courses and research. Students cited the greatest workload challenges during their first semester, as they adjusted to medical school; and during 3rd year, as they completed their master’s thesis, studied for the boards, and prepared for clinical clerkships: It’s really great to get all of these exposures, but sometimes it can also be really challenging to do these additional things outside of school, and being a med student, and being in our Master’s [program]. (2nd-year PRIME-US student)
The Clerkship Years During their clinical clerkships, the JMP PRIME-US students reported that they continued to experience the benefits and challenges discussed in previous years. A new theme that emerged was the feedback that they received from attending physicians and residents on clinical rotations. The students cited positive feedback about their strong clinical preparation to care for underserved populations but also some criticism of their career choices in primary care or family medicine. Clinical preparation to care for underserved populations. The PRIME-US students reported finding that they possessed greater knowledge about health disparities than their peers and confidence to advocate for underserved populations in clinical settings. Several students noted that non-PRIME medical students, residents, and attendings positively affirmed their ability and willingness to care for patients from underserved populations: Talking to residents . . . who had gone to other schools where there wasn’t as much of an emphasis or . . . an opportunity to work in a county hospital. . . . ‘Wow, you’re really getting a different education than what I got.’ (4th-year PRIME-US student)
Criticism of career choices in primary care and family medicine. During their 1st year of clerkships, PRIME-US students described trying to learn about all medical specialties while maintaining their commitment to underserved populations. Although PRIME-US encourages students to pursue whatever medical specialty may interest them, many PRIMEUS students are committed to careers in primary care and family medicine. Some students mentioned that, on various rotations, attendings and residents made derogatory comments about careers in primary care, which they felt uncomfortable having to defend: I feel like working with underserved, it’s not like people are really going to challenge you on that issue. But family medicine— throughout the year, I got a series of lectures. . . . I just decided I’m going to sit here and nod. (4th-year PRIME-US student)
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3. Increase Awareness Among JMP and UCSF Students About Health Disparities and Underserved Populations We gathered comments about the impact of PRIME-US on the JMP from the survey of all JMP students, faculty, and staff and the PRIME-US student focus groups. From both sources, mostly positive comments emerged, primarily regarding the value of enriching the medical school curriculum with health issues for underserved populations. However, challenges were also identified, particularly the additional workload involved, and concerns about unequal opportunities for students to participate in the program.
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Survey of Entire JMP Response rates to the four annual surveys ranged from 53% to 77% among approximately 70 JMP faculty, staff, and students. For open-ended questions, responses could be coded into more than one theme. Consequently, we could not do direct numerical comparisons of the raw responses across years. Instead, we calculated individual themes as percentages of responses within years, thereby allowing for comparison of theme percentages across academic years. The most common positive impact cited was that PRIMEUS increased the general program-wide support for caring for underserved populations, and specifically increased the curricular opportunities through seminars, community activities, and clinical preceptorships with underserved populations for all students. The most common negative impact cited was the increased workload related to the new program and activities.
PRIME-US Student Focus Group Comments Students in the pilot year of PRIME-US expressed enthusiasm about helping to build a new program, but they were also concerned about programmatic issues such as defining PRIME’s mission and policies, clarifying how the program would function within each medical school and across campuses, and securing adequate funding and staff/faculty support. Most PRIME-US students experienced substantial benefits from program participation and strongly felt that supplementary educational and service opportunities with urban underserved populations should be extended to the entire JMP community. The JMP is a small medical school where students work closely together in a collaborative small-group process. Given that PRIME-US students are philosophically oriented toward recognizing and eliminating disparities, and promoting social justice and “equity,” they felt uncomfortable with inequities in medical education opportunities. For example, one 2nd-year PRIME-US student stated: Keeping those [underserved seminars] open to everyone in the JMP . . . it’s hard to get busy people pinned down to a time, but that’s a really important piece to keep going.
4. Increase the Number of UCSF Medical School Graduates Working to Improve the Health of Underserved Populations During the focus group discussions and subsequent followup contact with PRIME-US graduates, all students expressed their continued commitment to work with underserved populations. Of the 16 entering JMP PRIME-US students from 2006 to 2010, 14 have entered medical residency programs, one has deferred residency selection, and one left medicine for another health career. There was a diverse representation of specialties, with the majority choosing primary care fields of family medicine (38%), internal medicine (12%), and pediatrics (12%); followed by emergency medicine (12%), psychiatry (7%), and ophthalmology (7%). Many non-PRIME students also chose to enter primary care specialties. DISCUSSION This was a mixed-methods study of the implementation of a new medical education program at the UC Berkeley–UCSF Joint Medical Program—PRIME-US—designed to recruit and train medical students committed to caring for underserved populations. This study demonstrated short-term effects of PRIME-US that were generally positive and consistent with the original program goals. The PRIME-US students identified many benefits including peer support, professional role models, mentorship, and curriculum enrichment activities that developed their knowledge and skills to care for underserved populations. Non-PRIME JMP students, faculty, and staff also benefited from participating in PRIME-sponsored seminars and community-based activities, noting that PRIME-US increased program-wide attention to issues for medically underserved populations. In addition, respondents noted implementation challenges including additional workload, limitations in clinical preceptorships, disparities among student educational opportunities, and some negative comments from physicians in other specialties about primary care careers. This evaluation shares similar findings with other evaluations of medical school programs for underserved populations, including the value of recruiting diverse and committed students; the benefits of curriculum enhancement, clinical experiences, and mentorship; the ability to sustain the commitment of graduates to underserved medicine; and the need to address disincentives for graduates entering primary care careers.16,20– 22,24,28,29 In addition, by conducting a “360-degree” process evaluation of program participants and nonparticipants, this study identifies additional challenges to program implementation such as increased workload, limited resources, and concerns about inequitable opportunities for students, which are important to address for successful program implementation. In particular, because the program goals include increasing the awareness and willingness of all medical students to care for underserved populations, it is critical to extend some program components to all students.
EVALUATION OF PRIME-US: THE FIRST 4 YEARS
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Each year, the results of the evaluation were reported back to students, faculty, and staff, and discussion was encouraged around priorities for program improvement. Based on the feedback, measures were taken to enhance the program. For PRIME-US students, improvements included clarifying the program mission, converting the preclerkship preceptorship to 2-year outpatient and 1-year hospital setting, and increasing student grant and scholarship opportunities. For non-PRIME students, improvements included increasing the availability of clinical preceptorships in underserved settings and extending opportunities to participate in underserved seminars and community-based activities.
CONCLUSION Longitudinal evaluation of elective medical school curricular additions can help demonstrate “value added,” adherence to original program goals, and ultimately long-term impacts. Over the first 4 years of PRIME-US, our medical school community experienced educational benefits consistent with the intended program goals to provide support, knowledge, and skills to care for underserved populations. The evaluation also demonstrated that schools should address the challenges of implementing new medical education enrichment programs— particularly the extra workload, the potential for inequities among students, and the need for consistent institutional support. Given that JMP and PRIME are small medical school programs, the results of this evaluation may not be generalizable to larger programs. Future studies should assess the longer term impact of the PRIME programs on healthcare workforce diversity and the supply of physicians caring for underserved populations.
ACKNOWLEDGMENTS We recognize and thank the following: Jennifer Wilson, Tami Rowen, and Joanna Eveland, who facilitated the focus groups and assisted in the analysis; Elisabeth Wilson and Aisha Queen Johnson who provided invaluable programmatic guidance and support; the entire JMP student, faculty, and staff community who shaped, experienced, and helped evaluate the curricular innovation; and the community health professionals and patients who contributed immeasurably to our medical students’ education. The UC Berkeley Committee for Protection of Human Subjects deemed this study exempt. Approval to conduct this evaluation was granted on October 24, 2006 (Reference ID: CPHS Protocol #2006-10-58).
FUNDING We thank the University of California Office of the President, and Anthem Blue Cross of California, who provided funding for PRIME-US at JMP.
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