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

1. A Scholarly Concentration in Health Disparities:Impact on the Primary Care Physician Workforce Cynthia Selleck, ARNP, DSN Program Director, University of South Florida AHEC Laurie Woodard, MD Associate Professor, Dept of Family Medicine Stephanie Peters, MA Associate in Education, Dept of Family Medicine University of South Florida College of Medicine Tampa, FL National AHEC Organization June 2010

2. 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)

3. 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

4. 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

5. 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.

6. 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)

7. 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.

8. 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

9. 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

10. “Flipping the Pyramid” Growing recognition that any health reform initiative should build upon a foundation of affordable, accessible primary and preventive care. Tertiary Care Tertiary Care Secondary Care Secondary Care Primary Care Primary Care Today’s health professional workforce is heavily focused on specialty care, with a shrinking number of U.S. trained physicians entering primary care.

11. 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.

12. 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

13. 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

14. 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.

15. Objectives of the Health Disparities SC Upon completion of this Scholarly Concentration, students should be competent to: • Describe barriers that exist for the nation’s medically underserved, against the complex dynamics of the U.S. health care system. • Investigate cross-cultural issues in health care and demonstrate how sensitivity to those issues (and others) improves health care for all. • Identify and evaluate sources of disparities in health care at the individual (patient and provider), institutional, and health systems levels.

16. 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.

17. 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.

18. 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.

19. 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

20. 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

21. 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.

22. 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.

23. Faces of the Homeless: a Scholarly Leadership Project Nicole Russell , MSIV Navid Eghbalieh, MSIV Health Disparities Scholarly Concentration Dr Lois Nixon served as Nicole and Navid’s Faculty Mentor April 7, 2010

24. 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

25. 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.

26. Evaluation • Students-Participation • Attendance, Logs, Project • Faculty mentors – Feedback • Informal • HDSC Co-directors – Feedback • Informal • Overall HDSC – Attendance/ Attrition/ SC Leadership

27. 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: • New students accepted into the HDSC have higher vicarious empathy scores than the remaining students in their medical school class. • Students admitted to the HDSC are more diverse (URM and/or disadvantaged) than the remaining students in their medical school class.

28. 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.

29. 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)

30. 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

31. Questions?