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Blueprint for Establishing an Effective Postbaccalaureate Medical School Pre‐entry Program for Educationally Disadvantaged Students

Blakely, Alan W. PhD; Broussard, Larry G. JD

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Dr. Blakely is Educational Programs Specialist, Office of Medical Education Opportunity Programs, University of California, Davis, School of Medicine; Mr. Broussard is Chief of Staff for Assemblyman Horton, California State Capitol, Sacramento.

Correspondence should be addressed to Dr. Blakely, Office of Medical Education, University of California, Davis, School of Medicine, One Shields Avenue, Davis, CA 95616; e-mail: 〈awblakely@ucdavis.edu〉. Reprints are not available.

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Abstract

The purpose of this article is to provide public and private medical schools with a pragmatic blueprint for the development and implementation of an effective medical school pre-entry program that increases the pool of students interested in returning to health care shortage areas. An ancillary benefit of this program is an increase in the number of underrepresented minority students to medical schools. The structure, experiences, and results of the University of California, Davis, School of Medicine's Postbaccalaureate Reapplicant Program are used as a case study to construct the blueprint for returning 85–90% of program participants to shortage areas while increasing minority student admissions. The UC Davis program has been in place since 1991 and post-program acceptance rates have varied from 57% to 100% with an overall acceptance rate of 90.4% through 1999–00. Of 115 participating students who had previously been rejected by medical schools, 104 were accepted to health professional programs: 95 students were accepted to major U.S. medical schools and nine were accepted to masters in public health programs, physician's assistant programs, and one international medical school. This success rate has been achieved through a combination of intense assistance in study skills and test-taking skills, academic course work, and academic and pre-professional counseling.

In 1994, 367 underrepresented minority Californians were rejected by all of the medical schools to which they applied for admission. In 1996, according to figures supplied by the AAMC,1 the number rose slightly to 379. These underrepresented minority students had completed the four to six years of an arduous premedical curriculum while preparing for and taking the Medical College Admission Test (MCAT) and coping with the year-long, complex medical school application process. Many of these students had been granted medical school admission interviews and some were alternates, but ultimately, none was accepted to any U.S. medical school. A total of 20% of all medical school applicants are from western states, and California alone accounts for 69% of this applicant pool.1 Because the proportion of California applicants is so large, a movement began to recapture this ready resource of underrepresented minority applicants via several affirmative action–based programs called postbaccalaureate reapplicant programs. This article describes the University of California, Davis, School of Medicine's Postbaccalaureate Reapplicant Program targeted at disadvantaged students, which was developed and implemented such that it is not dependent upon ethnicity and/or race in selecting its participants. This unique outreach program, which can serve as a blueprint for others, has consistently placed more than 80% of its students into medical schools and/or related health professions curricula throughout the United States. The program has evolved since its inception in 1991 and is no longer affirmative action–based, but it still serves to increase enrollment in medical schools for underrepresented minority and other disadvantaged students.

Nationally, a number of programs have been successful in improving underrepresented minority students' applications to and retention in medical schools. Most of the published accounts deal with undergraduate enrichment programs,2,3,4,5,6,7 which address a variety of issues in their attempts to assist students, including exposures to biomedical research and clinical settings, general academic preparation, and MCAT preparation. These programs generally report high rates of acceptance to health professional schools,2 and work is being done to show that they provide students with the skills requisite to succeed in medical school.3,5,6 However, the literature on postbaccaluareate programs, specifically, is not nearly as rich.

Wayne State University has had a postbaccalaureate program since 1969.8 This program was initially open to African American students only but expanded its eligibility to all disadvantaged students in 1978. Students in the program take upper-division science courses chosen to provide them with a strong enough science background to be successful in the basic medical sciences. Successful completion of these courses with a B average over the one-year duration of the program guarantees admission to the medical school. From 1969 to 1992, 90% of the program's participants matriculated, and 83% graduated.

The Medical Education Development Program (MEDP) at the University of North Carolina, Chapel Hill, has evaluated its program's success between 1981 and 1990.3,5 This program is open to students who have completed at least their junior year in college, as well as to students who have earned a college degree, so it is both a postbaccalaureate program and an undergraduate enrichment program. It simulates the medical school's first-year curriculum in a nine-week program and includes basic science course work; academic development; and exposures to clinical settings, health professionals, administrators, faculty, and policymakers. The evaluations show that 73% of the students completing the program were accepted to the university's medical school. The retention rate for these students varied between 94% and 96%, and the students were generally less likely to require mandatory summer review, deceleration, or dismissal,3 and graduated in a timely manner.5

Michigan State University has sponsored the Advanced Baccalaureate Learning Experience (ABLE) since 1986.9 Like Wayne State's program, ABLE is a conditional admission program that allows students to enroll in some first-year medical school courses and upper-division undergraduate science courses. This program is specifically geared toward underrepresented minority students, and the study reports comparisons between ABLE students and non-ABLE minority students. ABLE students demonstrated a significantly higher performance than non-ABLE minority students, and most ABLE students continued to meet the performance criteria necessary to maintain their good standing at the university.

Other literature has addressed the issue of the success of postbaccalaureate and other special-admission students at individual universities. Jefferson Medical College examined the entering classes of 1985 and 1987 and looked for differences in performances between students with postbaccalaureate experiences prior to medical school admission and those without.10 This study found that, although students coming in with postbaccalaureate experiences had lower undergraduate grade-point averages (GPAs) and MCAT scores than did students without such experiences, they were generally successful in medical school. The authors recommended that postbaccalaureate students be given favorable consideration and treatment in the admission process because they bring a diversity of experiences and tend to be more mature than applicants coming directly from their undergraduate degrees.

Brown University examined the performances of students who entered the medical school after postbaccalaureate work,11 fully one third of the students attending the medical school. No statistically significant difference was found in the academic performances of students with postbaccalaureate experiences versus those without. However, the postbaccalaureate students were significantly older than were the other students, and they had a commensurately greater range of background experiences. Some students had done graduate work in philosophy and art, some were professional musicians, some had attended seminary, and some had been teachers for the deaf. This is a potentially very rich pool of applicants for increasing the diversity, in the broadest sense of the word, of a medical school cohort.

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THE UC DAVIS SCHOOL OF MEDICINE'S POSTBACCALAUREATE REAPPLICANT PROGRAM

The Postbaccalaureate Reapplicant Program at UC Davis School of Medicine has evolved, consistently matriculating over 80% of its students in medical and/or health professional curricula (e.g., master's in public health or physician's assistant programs). The program concentrates on reapplicant students who are likely to return to designated medically underserved communities and/or who are educationally or financially disadvantaged. The program consists of ten weeks of intensive summer study and testing-skills preparation and three quarters of upper-division science course work, all taking place at UC Davis.

Students accepted to the program receive extensive guidance and counseling regarding establishing a competitive academic record. They are also given instruction and support in retaking the MCAT, writing an effective personal statement, completing the American Medical College Application Service (AMCAS) application, selecting appropriate medical schools, and preparing medical school secondary applications. Students are required to attend seminars on relevant medical issues in underserved communities plus a special session dealing with interviewing techniques.

The program begins nine weeks before the summer MCAT test is scheduled with study, test-taking instruction and strategies, and intense content review. Students are assisted not only in mastering the prerequisite medically-related science content areas, but also in augmenting their verbal reasoning, reading-effectiveness, and writing skills, in the application and acceptance process, and in other relevant preparatory areas. Following the summer activities, the students retake the MCAT. The tenth week of the summer is dedicated to polishing and submitting AMCAS applications. For the academic component of the program, students enroll in 12–15 units per quarter of upper-division science course work as “limited-status” students during the fall and winter quarters. (Limited-status students are not eligible for financial aid other than loans.) The students' classes are selected during the summer in consultation with the postbaccalaureate faculty and director. The students are challenged to maintain a 3.5 GPA or better; although there is no minimum requirement of achievement in the program, it is heavily stressed that only performance at this level will result in a successful reapplication to medical school. Throughout the summer and academic quarters, the students work on completing and refining their medical school applications. During the fall quarter, the postbaccalaureate students also attend a series of motivational and educational seminars covering a wide variety of health care issues.

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Outreach Efforts, Admission Criteria, and Selection of Students

Prior to 1994, UC Davis simply limited program participants to underrepresented minority students. However, in anticipation of the Regents' edict against using ethnicity as an admission criterion, officials of the program changed its admission practices and focus to reflect a race-neutral approach. In making this change, it was agreed that the program should focus on a compelling state health care need and address that need in its selection criteria. In California, there is no dispute over the need for more health professionals in state-designated medically underserved communities. There is also no dispute that the problem is not one of having too few physicians but rather a gross maldistribution of physicians. Such communities suffer unique disparate practices in seeking and acquiring health care,12 so the UC Davis Postbaccalaureate Reapplicant Program focuses its selection criteria and admission processes on meeting this state need. Heavy emphasis is placed on a student's educational, social, and financial disadvantages because they are strong indicators of where these students will practice medicine as physicians.13,14 Our fundamental hypothesis, in concurrence with Moy and Bartman13; Carlisle, Gardner, and Liu14; and others writing in a similar vein, is that students will return to practice medicine in the same sorts of communities in which they grew up.

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Recruitment and outreach

Recruitment for the program begins in February each year. A list of potential applicants is generated from the AAMC's Medical Minority Applicant Registry (MED-MAR); announcements in Health Pathways, a regular publication of the state's Health Professions Careers Opportunity Program (HCOP); referrals from other statewide HCOP staff, college premedical counselors and other advisors; articles and announcements in undergraduate and graduate minority student organizations' newsletters; and announcements and distribution of the program's brochure at premedical students' conferences and undergraduate pre–health-professional club meetings. By early March, materials are sent to all identified applicants. Prospective applicants receive the program's brochures, a letter discussing the program, a course outline, an application, and other school-related materials. Outreach is limited to California residents because the expensive out-of-state tuition charge would simply be prohibitive for most students.

Currently, there are no legal or policy limitations or restrictions on outreach efforts based on race or ethnicity. Although selection and admission criteria are race-neutral, outreach efforts can directly target minority students. In our experience, most students who meet our criteria for a likely return to care shortage areas and for being disadvantaged are from underrepresented minority groups. Thus, much of our outreach effort is directed toward these students.

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Three admission criteria

A race-neutral admission criterion. The first review of a postbaccalaureate applicant tries to determine whether the student shows promise of returning and practicing in a medically underserved community, but this screen excludes race because race does not assure this occurrence. For this factor, reviewers look for the applicant's relevant contact or experiences with state-designated medically underserved communities or populations. Social and/or financial disadvantage in early childhood are also taken into account. The reviewers scrutinize the applicant's voluntary and involuntary involvement in such communities from elementary school through college. Any level of demonstrable involvement is sufficient to make the initial screen. For example, tutoring at-risk students or volunteering in a medical clinic located in an underserved community, receiving government financial or housing assistance, or simply residing within such a community as a child will all suffice to pass the initial screen.

Can the program help the student? The next criterion is whether the program can help a particular student. The reviewers determine that the program's structure and requirements will benefit the applicant after a review of the student's academic credentials and MCAT scores. Generally, our most successful students enter with GPAs between 2.5 and 3.2 and MCAT scores between 4 and 7 on each subtest. However, this is only a rough guideline. Although grades and test scores have some relevancy, they are not nor should they be the sole indicators of an applicant's success in the program or medical school.15 This criterion is considered critical because each student will have to make serious time and financial commitments to finish the program. Exceptions to the general academic guidelines are made based on several factors, including letters of recommendation, personal circumstances, and information gained from the student's interview. Students with lower test scores and grades are frequently admitted. The deciding factor is that reviewers must be satisfied that the student can successfully enter medical school upon reapplication and completion of the program. Students outside the upper end of the general range given are often advised to consider other postbaccalaureate programs because they may not need the intense assistance offered by this program. These students often need only to revise their medical school applications or put in a good showing on the MCAT to gain admission to medical school; in these instances the time and expense of completing our program could be more profitably invested elsewhere. Once it is determined that an applicant meets the criteria on paper, an interview is granted.

Interviews. This selection criterion is the determining factor for admission to the program; it is used to confirm that the student has met all of our selection criteria and will be successful upon completing our program. The interview process is designed to gain thorough information about the student's educational and family backgrounds, academic strengths and weaknesses, and overall motivation and mental attitude. The program director and the educational-program specialist who administers the summer component conduct the structured interview. Applicants are asked:

1. In your opinion what do you need to do to improve your MCAT scores?

2. What improvements and/or adjustments do you need to do to improve your science GPA?

3. What is your most valuable volunteer experience and why?

4. If you were granted your MD degree today, what would you do?

5. What do you consider the top three major issues facing medicine today?

6. Ethical questions (i.e., If you accidentally ran into an old undergraduate colleague who is also an MD on his/her way to see a patient and you discover he/she is high on alcohol or drugs, what would you do? You discover one of your classmates is addicted to drugs. What would you do?)

7. If your best friend were to describe the type of person you are, what would he/she say about you? (The same question is asked only enemy is used instead of friend.)

8. When you are depressed or feeling down, where do you go to seek support?

9. Please describe the community environment with which you identify and in which you would feel the most comfortable establishing a medical practice.

10. What are the major health issues and/or concerns within that community?

11. Please describe any leadership positions you have held from high school to now.

12. What was the most valuable lesson you learned from those experiences?

13. Have you applied to other postbaccalaureate programs?

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Selection of students

After the interviewing process is completed, students are re-evaluated by the interviewing team and either admitted or placed on the first- or second-alternate list. If any student is to be selected from the alternate list, another review is made of all students on the first-alternate list before a selection is made. The criteria for gaining admission include:

1. motivation—as judged by personal interviews, letters of support, AMCAS personal statement, postbaccalaureate statement of purpose, and responses to application questions;

2. reasonable explanation and solutions for poor to mediocre GPA and MCAT scores (e.g., worked 30–40 hours per week while in college, repeated or chronic family problems, too much community or political involvement while in college, etc.—realistic self-assessment is critical to success as a postbaccalaureate student);

3. relevant interest, background, experience, and potential for practice in urban or rural underserved communities;

4. undergraduate college GPA: postbaccalaureate students should have overall GPAs in the 2.5–3.2 range, with science GPAs in the 2.3–2.8+ range;

5. previous MCAT scores: postbaccalaureate students should have average MCAT scores on the three numerically scored subtests in the 4–7 range and M-O on the writing sample. (Students should not be denied if they score 3 on Verbal Reasoning and M-O on the Writing Sample but should be re-evaluated before acceptance to the program)

Although ethnicity is not used as a selection criterion, the existing criteria have resulted in program cohorts composed predominately of underrepresented minorities. The class demographics for 1991 to 1999 are shown in Table 1.

Table 1
Table 1
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Program Components
Summer study and testing skills session

The summer sessions dealing with critical reasoning, study and test-taking skills, MCAT review, and a review of basic math concepts is residential; the students live in dorms on campus. The summer session is essential in preparing the students to maintain the required GPA in the academic component of the program and in building the necessary study skills and habits to successfully complete the medical school curriculum. Students are exposed to a number of techniques and habits of successful students and are encouraged to incorporate these into their own lives. The other activities and the pace of the summer component are designed to give ample opportunities to practice and develop these skills.

Early in the summer, each student identifies his or her weakest two topics from the MCAT, and they present these topics in review sessions for the rest of the class. These review sessions start in the third week and continue to the end of the summer, interspersed with other activities. The benefits of these presentations are threefold. First, by tackling their weakest subjects, students are doing the most productive reviews in the short time available to them before the MCAT. Second, other classmates are likely to be strong in these topics, and as they help each other prepare for their presentations they develop confidence, trust, teamwork, and a group identity that are very important to them throughout the year of the program. Third, they develop confidence in their own abilities; once they have dealt with the two subjects that are the most difficult for them, students feel they can deal with any topic matter. These review presentations are the sole MCAT-specific science review component of the program.

Substantial time is spent reinforcing and expanding the skills necessary for the Verbal Reasoning and Writing Sample sections of the exam. These sessions include a variety of activities designed to bolster reading speed and comprehension, logical analysis and evaluation of statements, and clear presentation of arguments. In addition to preparing for the MCAT, the writing activities are aimed at preparing students to write good essays for their primary and secondary medical school applications.

The students also participate in sessions dealing with the necessary study and problem-solving skills for taking standardized tests, particularly the MCAT. This instruction is designed to specifically assist students with testing strategies and thinking modalities inherent in all standardized tests. These sessions range from basic tips, such as answering every question, through more sophisticated exercises in evaluating given choices for reasonableness and exercises in logic and inference.

A new piece was added to the summer component of the program for 1998–99. Because critical thinking and problem-solving skills were not being adequately developed, an introductory physics course was added to the summer curriculum. This course takes place primarily in the laboratory, but instead of a a formal laboratory manual that specifically delineates experimental procedures, the teaching assistant presents the group with questions such as, “What would happen if…?, Why does this phenomenon occur? How would you explain…?” Students are given time and equipment, but they are responsible for designing experiments and making observations that will allow them to answer these questions. This is a very challenging course, not only for postbaccalaureate students, but also for the undergraduates who take the course. It requires that students master concepts from a fundamental level rather than rely upon rote memorization; most of the mathematical equations needed for the course are derived from the physical relationships observed.

For each year our students have been engaged in this physics class we have seen a recurring series of reactions. At first the students find the course very difficult and time-consuming. They often complain that they feel that it is taking away from time they could be more productively using doing other things such as studying for the MCAT. However, as the summer progresses, students start making use of the skills and ideas from the course in their own presentations and grudgingly acknowledging that they are seeing a change in the way that they approach problem solving. By the end of the summer, just before the MCAT, students are usually making much more positive comments about how they have transformed their problem solving—they are no longer simply seeking the “right” equation to reduce a problem to a “plug and chug” situation, but are approaching problems from a fundamental level that allows them to really understand what they need to solve the problem and what is extraneous information. After taking the MCAT students often are very excited about having been able to use these skills across all of the science subjects on the exam.

The program fosters a cooperative learning environment by making study groups an integral part of the summer program. The study and testing-skills seminars make extensive use of group work, and students are encouraged to study together and incorporate group work into their content review presentations. Additionally, group work is a major component of the introductory physics laboratory. We have found that this environment is very important to the students' success throughout and after the program. This group work fosters a strong esprit de corps in the class. Students continue to support each other throughout the academic year, both lending moral support and sharing knowledge and experiences. Many students draw a great deal of strength from having colleagues who share the same goals and are in the same situations as themselves.

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Application preparation

After the students take the summer MCAT exam, they are required to confer with postbaccalaureate faculty and staff and complete the AMCAS or AACOMAS application process. At this point, they are given guidance in all phases of the application process, from the selection of schools to the writing of the personal statement.

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Academic component

Upon completing the ten-week summer session, the students enroll as limited-status students at the University of California for the following three quarters—not in courses specifically taught for the postbaccalaureate students. Students receive counseling in their choices of courses with an emphasis on helping each student design a course load specifically suited to that individual. They may enroll in any upper-division science course regularly offered by the university, subject to the requirement that they not repeat a course they have taken as an undergraduate or graduate student. Students typically choose courses in: biological sciences; cell biology and human anatomy; family and community medicine; microbiology; molecular and cellular biology; nutrition; neurobiology, physiology, behavior; pathology, microbiology, and immunology.

Seminars. To supplement the academic component, the following minority health care issues and leadership seminars are scheduled to help students with interviews:

1. Health economics and financing health care in ethnic minority communities and health manpower shortage areas; plus historical perspective on health care reform in the United States

2. Practical mechanics of various interviewing techniques

3. Health maintenance organization structure—advantages and disadvantages

4. Osteopathic medicine in a changing medical environment

After the seminars, the students are scheduled for videotaped mock interviews, which are critiqued by program faculty and staff.

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Program Results

The UC Davis Postbaccalaureate Reapplicant Program has proven to be successful in all areas of endeavor. Students participating in the program have improved their performances on all sections of the MCAT, and they have substantially improved their academic performances in rigorous course work. For 1991 through 1999, 104 of the 115 participating students (90.4%) were accepted by various medical programs after previously being rejected by all schools to which they had applied. Of the 104 accepted students, 93 were accepted by major U.S. medical schools. The other 11 were accepted at master's in public health programs, physician's assistant programs, and one Mexican medical school. Students who are accepted to master's or physician's assistant programs usually reapply to medical school after completing the degree and are often accepted to medical school. Five of the eight students accepted at health professional programs will be reapplying to medical school, and three have opted for terminal master's degrees. Acceptance rates vary by class from 57% to 100%. Graduates of the program are being tracked after completing medical school to determine the extent to which the goal of returning physicians to care shortage areas is being met. Of particular interest will be the postbaccalaureate class of 1994–95 because that is the first class selected specifically based on the criterion of returning to care shortage areas.

Table 2 shows the changes in MCAT scores for the students participating in the program. In general, these results compare favorably with the reported values for students retaking the MCAT after taking a commercial review course (0.8 in Verbal Reasoning, 0.7 in Physical Sciences, 1.1 in Biological Sciences, and 0.3 for the Writing Sample).16 In some cases, particularly in the Physical Sciences and Writing sections, gains by our postbaccalaureate students dramatically exceed the reported values. Scrutiny of these numbers shows that the program has greater success with students who have previously performed poorly than it does with students who have previously performed well on the MCAT. This is due to the program's focus on developing good study and test-taking skills over mere content review. Students who score well on the MCAT already have many of the skills emphasized during the summer component and benefit less; these students need emphasis on content review to show more dramatic gains on the MCAT. Notably, many of the gains are statistically significant, sometimes at excellent p values. Only students who had full sets of pre- and post-program MCAT scores and GPAs were used in calculating the statistics given in Tables 2, 3, and 4. Students missing any of these data, due, for instance, to being accepted to medical school midway through the summer program, were excluded from these calculations. Thus, fewer students are reported on these tables than have participated in the program and are counted in Table 1.

Table 2
Table 2
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Table 3
Table 3
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Table 4
Table 4
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Table 3 shows how the students' scores changed when grouped by range, both before and after the program. For example, on the Verbal Reasoning exam five students entered the program with test scores between 1 and 4 and finished the program with scores in the same range; 17 students came into the program with scores between 1 and 4 and finished the program with scores between 5 and 7. This table reinforces that the program's MCAT preparation component is preferentially useful to students with low- to middle-range test scores. Another potentially interesting statistic is that the maximum change in the composite score of the three numerically scored tests is 9, the minimum change is −4, and the average change is 2.20.

Table 4 shows students' performances in the academic component of the program. In all cases, GPAs have significantly improved. The mean change in GPA shown in the table was calculated by comparing the students' entering science GPAs with the GPAs they achieved while in the program, not with a new cumulative science GPA including both their old and new grades. The academic component is considered the most important aspect of the program because the students establish that they have dealt with whatever difficulties kept them out of medical school on their previous applications. To be successful in this component, the students must demonstrate they have acquired the discipline, focus, and study skills they previously lacked and are capable of performing well in a rigorous academic curriculum.

In addition to looking at these students as a group, it is interesting to focus on a few typical students, each of whose names has been changed to protect their privacy. Miguel was a Mexican American student of the program in 1993. He came in with a science GPA of 2.45 and MCAT scores of 5, 6, Q, 6 (Verbal Reasoning, Physical Sciences, Biological Sciences, respectively).

After the summer component his MCAT scores improved to 6, 7, Q, 5 in the same categories, and his GPA during the academic year was 3.13. He was accepted to Michigan State University College of Human Medicine and graduated in four years. He passed all three steps of the United States Medical Licensing Exam (USMLE) with scores of 190, 196, and 197 and is currently a resident in family practice at Martin Luther King/Drew Medical Center in Los Angeles, California.

Carlos, a Hispanic classmate of Miguel's in our program, entered with a 2.51 GPA and left with a 4.00. His MCAT scores changed from 6, 7, Q, 8 to 9, 6, P, 9 (Verbal Reasoning, Physical Sciences, Biological Sciences, respectively). After graduating from the Chicago School of Osteopathic Medicine in 1999 with Comprehensive Osteopathic Medical Licensing Exam (COMLEX) scores of 650, 480, and 600, he moved on to a residency in family practice at Arrowhead Regional Medical Center in San Bernardino, California.

Sandahl, an African American woman from the class of 1994, showed a similar level of success. Her entering statistics were a 2.63 GPA and scores of 6, 5, O, 6 (Verbal Reasoning, Physical Sciences, Biological Sciences, respectively) on the MCAT. She chose the University of California, Davis, School of Medicine from multiple acceptances after posting a 4.00 GPA and MCAT scores of 7, 8, P, 8 in the same categories. She is currently a resident in family practice at UC Davis and has passed the first two steps of the USMLE with scores of 210 and 200.

As can be seen, all of these students came into the program needing to significantly improve their academic profiles, performed well while here, and subsequently have been successful in their medical training. To date five of our students have become practicing physicians, and four of them are practicing in medically underserved communities.

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Program Costs and Support

The UC Davis program operates on an annual budget of approximately $225,000. About $110,000 goes to personnel expenses, $95,000 is dedicated to non-personnel program expenses such as housing and materials, and the balance goes to operating expenses. The California Endowment has been very gracious in its funding and support of the program in the past four years. The director and the education specialist are full-time employees and a number of other positions are part-time: a research assistant employed half-time year round; summer instructors in writing/verbal skills, mathematics, and physics lab; and secretarial support shared with other admission and outreach programs. The cost to students is substantial. The program pays for students' expenses associated with housing and program materials for the summer, but the students are responsible for their academic year expenses. A full-time student at Davis for a year pays approximately $14,000. Students can generally qualify for up to $10,500 in student loans and must make up a shortfall of about $3,500. One of our current projects is to find a way to narrow that gap so that we are not pricing our target population out of our program.

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DISCUSSION

The success of the UC Davis School of Medicine's Postbaccalaureate Reapplicant Program is important on two fronts. The program is increasing the number of successful medical school applicants who are committed to returning to medically underserved communities. It is doing so without resorting to contracts or inducements such as loan forgiveness, avoiding the administrative time and expense such programs require. By focusing on educationally disadvantaged students who are personally committed to returning to shortage areas as physicians, the program also increases the number of underrepresented minority and other disadvantaged students who gain admission into medical school. This helps increase the diversity of the medical student population, a goal that the AAMC is actively pursuing. This is done without using race or ethnicity as selection criterion, which avoids potentially divisive and damaging political controversies.

The second major success of the program is its ability to rehabilitate students who have encountered severe educational obstacles. In terms of getting the students into medical school, those selected for this program are at greater risk than are those selected for many other programs requiring students to have received an interview with a medical school or have higher minimum MCAT scores. The UC Davis program's success rate for getting these students into health professional programs is excellent. Most graduates are accepted into major U.S. medical schools, and many of the remainder are accepted into public health or physician's assistant programs.

The UC Davis program succeeds by focusing on improving students' academic skills rather than content review, which is important to keep in mind when examining changes in students' performances. The program is most successful with students who lack important study skills and is less successful at improving performances of students who primarily need content review to meet the standards of medical schools. This pattern of success is clearly shown in Table 2. Classes with low mean MCAT scores upon entering the program generally demonstrated the greatest improvement, and classes with high mean scores upon entering the program demonstrated less improvement. Table 2 shows that students generally leave the program with scores of 7 and 8 on the MCAT, although 10 and 11 are not uncommon MCAT scores. Students who come in with scores of 4 and 5 show more improvement than do students with scores of 6 and 7. This pattern is important to keep in mind when selecting participants; students above a certain level of achievement may not be well served by our program and will be more successful in a program designed to assist high-end candidates. For example, the class of 1997–98 showed no statistically significant change in its performances on the MCAT. This was the strongest class to date. The students' scores upon entering were difficult to improve using the program's methods.

As we mention in our description of the program, it has been evolving. In its development, each component has been carefully selected to address a perceived need of the students. The study and testing skills seminars address their need for stronger academic skills that many of their more successful peers have already mastered. The verbal reasoning and writing skills sessions address their need to be able to use language effectively; this is particularly important for the majority of our students because English is their second language. The science review sessions reinforce their science knowledge; address specific, substantial weaknesses; and build their self-confidence. The laboratory physics course dramatically improves the students' critical thinking and problem-solving skills. The application assistance ensures that students present themselves professionally. The course work in the academic year allows the students to prove that they have mastered the issues that have previously been impediments to their success. The fall seminar series educates them about important issues in the application process and in their professional careers. This has not been an experimental process in the sense that the performances of control versus treatment groups have been examined under carefully controlled conditions, but the process has been scrutinized for ways to improve the practical success of the program. When a need is identified, a piece is designed to meet that need. The results are looked at critically, and adjustments are made to ensure that the new piece is doing its job. The addition of the physics class has been the subject of a formal research study, and it has been confirmed that it does indeed contribute that for which it was chosen. That study will be presented elsewhere.

Finally, we comment on one aspect of the program that requires careful consideration by others who may be interested in incorporating features from our program into their own. The UC Davis program does not have a conditional admission agreement with the university's medical school. Some programs, such as Michigan State University's, have an agreement with an associated medical school that if a student successfully completes the postbaccalaureate program then admission to the medical school automatically follows. The UC Davis program has deliberately avoided such an arrangement to maintain its freedom to make progressive and aggressive changes in its curriculum in the effort to reach and assist the target population. If a medical school were to commit to accepting the students produced by the program, the school would justifiably want some degree of control over programmatic changes and could force a more conservative approach or the admission of “safer” students.

In conclusion, it is possible to construct a structured postbaccalaureate medical school program that addresses several pressing concerns. Our program produces competitive medical school applicants who are personally committed to practice in medically underserved communities, and it increases underrepresented minority admissions without using race or ethnicity as a selection criterion. This program has achieved an overall placement record of over 80%, with nearly 100% placement in several classes. Retention upon matriculation is being studied and is also believed to be excellent. This program, and others like it, should prove to be an efficient and cost-effective means of providing underrepresented minority health professionals for service in underserved communities over a relatively short time span compared with other expensive long-range recruitment efforts and strategies such as those targeted at high schools.17

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