A Scholarly Concentration in Health Disparities: Impact on the Primary Care Physician Workforce

Cynthia Selleck, ARNP, DSNProgram Director, University of South Florida AHECLaurie Woodard, MDAssociate Professor, Dept of Family MedicineStephanie Peters, MAAssociate in Education, Dept of Family MedicineUniversity of South Florida College of MedicineTampa, FL

National AHEC Organization

June 2010

History of Scholarly Concentrations at USF

A “concept” of the Education Strategic Work Group, 2005

SCs are topic areas that medical students can select to study in greater detail – a “minor” of sorts

Voluntary rather than mandatory Components include course work, practical

application and scholarly presentation The equivalent of 12 semester hours (180 contact

hours)

History of Scholarly Concentrations at USF

In 2006, interested faculty volunteered their time to design and organize SCs

SCs began accepting students in fall 2007 Currently completing our 3rd year of SCs Interested students complete an application to

join the Scholarly Concentration Program plus an application for the specific SC they wish to join

Current SCs Offered at USF

– Business & Entrepreneurship– Medical Education & Leadership– Health Disparities– Research– Law & Medicine– Public Health/Global Approaches to Clinics &

Communities– Health Systems Engineering*– Humanities*

* New for 2009-2010

Why an SC in Health Disparities? Some students were already doing significant

volunteer work in this area (ex: BRIDGE Healthcare Clinic)

We wanted interest in the topics of health disparities, care of underserved populations and healthcare justice to be valued as much as areas such as Business, Research, Education, Law, etc.

We also wanted to mentor those students who came to medical school seriously interested in the topic.

Recruitment of Students into SCs Promotion occurs during the secondary

application and interview process Overview of SCs provided during orientation

(within 1st week of school) SC Informational Round Robin evening during

Sept-Oct (“speed dating”) Applications due late October Selections made by December (but students can

join later as well)

The Health Disparities SC is for students who want to:

Exercise your altruism! Provide care for those who

have limited access. Discover why health

disparities exist. Design an intervention to

eliminate health disparities. Learn how to improve the

system for all.

Some Background:

Current Status of the Primary Care Physician Workforce– In 2008: 240,416 PCPs (1 for every 1,281 persons)– Currently a problem of distribution

• Still concentrated in desirable areas• Relative shortage in underserved and rural areas• True for physicians, NPs and PAs

Horizon Problem Research indicates that access to primary care

is associated with better health outcomes and lower healthcare costs; however:– Decline in U.S. student interest (though increased

slightly in 2010)– Increased reliance on IMGs– Increased interest in specialization (ROAD)– Contraction of training programs– Current physician expansion effort not promoting

primary care

“Flipping the Pyramid”

Tertiary Care Secondary

Care

PrimaryCare

Tertiary Care

SecondaryCare

PrimaryCare

Growing recognition that any health reform initiative should build upon a foundation of affordable, accessible primary and preventive care.

Today’s health professional workforce is heavily focused on specialty care, with a shrinking number of U.S. trained physicians entering primary care.

How to Flip the Pyramid In order to build a base of primary care providers,

we must reverse the decline in the number of U.S. healthcare professionals entering primary care and create incentives for a strong primary care workforce that can meet the health challenges of the 21st century.

What Influences Medical Student & Resident Choices?

Debt – plays an important role for some but not most students

NHSC – growing interest among students Title VII programs – important role in facilitating

the choice of primary care, practice in underserved areas and service to medically needy

Physician income gap/Return on Investment

From: Robert Graham Center, March 2009

What Influences Medical Student & Resident Choices?

Training in rural locations – important to choosing practice in rural locations

Attending a public medical school Student interest in caring for underserved populations

(increased likelihood of practice in an FQHC and serving in NHSC):– Schools should give weight to this in acceptance– Target these students for mentoring and training experiences

From: Robert Graham Center, March 2009

Mission of the Health Disparities Scholarly Concentration

Our mission is to provide USF medical students interested in the topics of health disparities, healthcare justice and care of medically underserved populations an opportunity to enrich their educational experience by focusing volunteer and supervised clinical experience and group and independent learning in these areas.

Objectives of the Health Disparities SC

Upon completion of this Scholarly Concentration, students should be competent to:

1. Describe barriers that exist for the nation’s medically underserved, against the complex dynamics of the U.S. health care system.

2. Investigate cross-cultural issues in health care and demonstrate how sensitivity to those issues (and others) improves health care for all.

3. Identify and evaluate sources of disparities in health care at the individual (patient and provider), institutional, and health systems levels.

Objectives (con’t)4. Identify and describe the unique opportunities and challenges that

medically needy populations present to medical practice.

5. Act as an advocate and design interventions to eliminate health disparities at the individual (patient and provider), institutional, and health systems levels.

6. Engage and reflect upon relevant clinical experiences throughout four years of medical school.

Student Participants Students who not only want to understand health care

inequities and costs in our society, but who want to be part of the solutions, are attracted to this scholarly concentration. Their concerns about health disparities are nurtured and supported through participation.

Faculty Mentors

Each student works with a faculty mentor from a group of approximately 20 interesting and interested people drawn from USF Health, USF main campus and the community.

Mentors help students to develop and tailor an annual scholarly plan, meeting with them regularly to assess completion of agreed upon experiences.

Program Activities & Requirements

Journal Clubs - monthly over the course of 3 years on 5 themes:

Overview of Health Disparities Health Economics & Policy Issues Social Determinants of Health Race, Ethnicity and Culture Disabilities & Special Populations

Program Activities & Requirements

Clinical Experiences – through the Longitudinal Clinical Experience (LCE) course, clerkships, and electives

Optional Summer Experience – individually negotiated clinical, community advocacy or research experience conducted during the summer between years 1 and 2

Program Activities & Requirements Volunteer Community Service – with medically

needy populations through the USF Health Service Corps, BRIDGE Healthcare Clinic, Judeo Christian Clinic, Project World Health, International Health Service Collaborative, and through HDSC community service projects.

Program Activities & Requirements Scholarly Leadership Project – individually

negotiated leadership project the goal of which is to design interventions to eliminate health disparities at the individual (patient or provider), institutional and/or health systems levels.

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Scho

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tionFaces of the Homeless: a

Scholarly Leadership Project

Nicole Russell , MSIV Navid Eghbalieh, MSIV

Apr

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20

10

Dr Lois Nixon served as Nicole and Navid’s Faculty Mentor

Program Activities & Requirements Optional Advocacy Activities – students with an interest in advocacy can

travel to Tallahassee or Washington DC to meet with legislators to discuss the needs of the medically underserved and advocate for change on their behalf.

And more! - participation in national conferences such as – National Summit of Clinicians for Healthcare Justice– Physicians for Human Rights – Migrant Stream Forums

Timeline for Completion Years 1, 2, 3: clinical and volunteer experiences and

monthly journal club attendance.

Year 4: Leadership project, mentor junior students, legislative advocacy.

Evaluation Students-Participation

– Attendance, Logs, Project

Faculty mentors – Feedback– Informal

HDSC Co-directors – Feedback– Informal

Overall HDSC – Attendance/ Attrition/ SC Leadership

Research: A Longitudinal Observation of the Impact of a Specialized Curriculum on

Empathy in USF Medical Students Background: research data indicate that empathy of

medical students decreases throughout the process of medical education

Hypotheses:1. New students accepted into the HDSC have higher

vicarious empathy scores than the remaining students in their medical school class.

2. Students admitted to the HDSC are more diverse (URM and/or disadvantaged) than the remaining students in their medical school class.

Hypotheses:3. Students in the HDSC will show less decrease

in overall empathy scores through their 4 years of medical school than the remaining students in their medical school class.

4. Students in the HDSC are more likely to pursue primary care (core) residency training than the remaining students in their medical school class.

Research Protocol

IRB approval Sept 2009 Studying class of 2013 Using a brief demographic questionnaire

and the 30-item Balanced Emotional Empathy Scale (BEES)

Instrument administered 5 times (beginning of years 1, 2, 3, 4 and end of year 4)

Challenges Faced to Date

Totally volunteer on behalf of faculty; no funding to support – and lots of work!

Students have full plates and tend to be “no shows” in their 3rd year

No grades given – therefore no grade incentive

Lots of student interest – how best to maintain and mentor “true” student interest over time

Questions?