Thomson, William A. PhD; Ferry, Pamela G. MHS; King, Jason E. PhD; Martinez-Wedig, Cindy PhD; Michael, Lloyd H. PhD
In 1994, Baylor College of Medicine (BCM) and The University of Texas–Pan American (UT-PA)—a predominantly Hispanic college, located in Edinburg, Texas—created the Premedical Honors College (PHC), an eight-year, college-through-medical-school program designed to increase the number of physicians addressing health care needs of underserved populations in Texas.
The program targets South Texas, a 13-county region in the southernmost tip of the state. The South Texas population is 81% Hispanic/Mexican American and has grown by 30% since 1990, to over 1.6 million.1 All 13 South Texas counties are designated as medically underserved; 11 also are identified as health-professional shortage areas.2 Four of the counties have fewer than five physicians, and one has no physician at all.3
The shortage of health care in South Texas is a product, in part, of the fact that very few students from South Texas colleges and universities enter medical school. In 1996 only 23 students from all five South Texas colleges (a combined student population of over 30,000) applied to medical school, and only four matriculated.4
The PHC has created a seamless pathway from high school through college and medical school to maximize recruitment and retention of highly qualified minority and disadvantaged students and to address the many obstacles these students face in accessing college and professional education. The PHC is making significant strides toward decreasing the gap in higher education enrollment between Hispanics and the overall student population. In addition, the PHC is helping to make the representation of students who enroll and graduate from Texas universities and medical schools more reflective of our state's population.
As of the fall of 2002, a total of 60 PHC graduates had matriculated into medical school, of whom 58 (96.7%) were Mexican American, 1 (1.7%) was Caucasian, and 1 (1.6%) was Asian. This number is significant on both a state and a national scale. In 2001, 115 Mexican Americans from Texas entered Texas medical schools, and 12 of these (10.4%) were PHC students. Nationally, 386 Mexican-Americans (2.3% of all matriculants) entered medical schools in the United States in 20015; 17 of these (4.4%) were PHC graduates.
The PHC is open to all graduates of South Texas high schools. Students apply during their senior year of high school. Selection is based on academic performance, SAT scores, letters of recommendation, and an evaluation of maturity, life experiences, interpersonal and communication skills, and motivation to pursue a medical career. (For an indication of admission standards, see the early part of the next section of this article.) Finalists are flown to Houston for interviews with BCM's Medical School Admissions Committee.
PHC students attend UT-PA for their college educations and receive conditional acceptance to BCM upon acceptance into the program. Those who fulfill all PHC requirements and BCM prerequisites are accepted into BCM upon graduation from UT-PA. PHC students are required to maintain an overall grade-point average (GPA) of 3.2 and a science GPA of 3.0 throughout their college studies, with no grade in prerequisite courses below a C. A warning system and a remediation program are in place for students who experience difficulty.
The UT-PA curriculum focuses on science, mathematics, and communications. All PHC students are required to major in biology or chemistry. Students who major in biology must minor in chemistry, and vice versa. The PHC emphasizes focused learning activities, with required tutoring and support services at each academic level, reinforced through structured enrichment activities. The PHC program coordinator (provided by BCM) is a UT-PA faculty member who interacts often with other UT-PA faculty and staff involved with PHC students to identify potential problems.
To enhance medical understanding and interest, throughout the program PHC students participate in clinical learning activities in a variety of settings, including private and federally funded clinics. Exposure to professional medical environments through preceptorships with physicians and site-based learning opportunities in local hospitals and clinics are an important aspect of the PHC. Working in area clinics and hospitals exposes students to cultural and health care issues affecting the local population. Such experiences help PHC students to develop relationships with local practitioners, who become mentors and maintain contact with the students during the college and medical school years.
In addition, all PHC students participate in summer programs during their college years. These experiences expose students to medical practice and biomedical research, and to other college students from across the nation. The goal is to ensure that all PHC students are able to participate in a full range of experiences to help prepare them for medical school and eventual pursuit of careers in medicine.
All PHC students are required to attend a six-week enrichment program in Houston the summer following their freshman year. The program, funded, in part, by The Robert Wood Johnson Foundation, is a partnership between BCM and Rice University. It includes rigorous coursework in science (anatomy and physiology) and English (medical communications). Students also are assigned to preceptorships with BCM faculty, to gain a first-hand glimpse into the day-to-day practice of medicine. They are exposed to the medical school curriculum and environment through integrated anatomy and physiology lectures focusing on major human organ systems, as well as experience in BCM's gross anatomy lab. The program also emphasizes development of the communication skills necessary for doctor–patient relations and interactions with other professionals in various medical settings.
In subsequent summers and during the academic year, PHC students participate in a variety of activities and research experiences in South Texas and elsewhere. Students have participated in clinical activities with South Texas physicians; attended summer research programs at BCM, UT-PA, and other U.S. medical schools; engaged in summer enrichment and review courses for the Medical College Admission Test (MCAT) at BCM, UT-PA, and other Texas medical schools; and pursued research or studies in Latin America. The PHC program coordinator assists students in identifying and applying to summer programs and arranging preceptorships with local physicians.
All students selected for the PHC, regardless of economic status, have their full tuition and fees covered during their four years of college study at UT-PA. For PHC students matriculating to BCM, all medical school tuition and fees are also covered. Many incidental costs (books, airfare, room and board for summer programs, stipends for summer programs, lab coats, backpacks, etc.) are covered, and UT-PA and BCM staff help to secure sufficient financial aid to assure students' completion of all program components. Since about 55% of PHC matriculants are classified as economically disadvantaged, many talented and ambitious PHC students would be unable to pursue college premedical studies and careers in medicine without such financial assistance. (Economically disadvantaged is defined by UT-PA and BCM as qualifying for federal and Texas economically-based educational grants and loans assistance, including Pell Grants, Perkins Loans, Texas Public Education Grants, and others.)
WHAT THE PROGRAM HAS ACCOMPLISHED
Applicants and Matriculants, 1994–2002
Data tracking for applicants and matriculants to the PHC includes pre-college academic indicators (GPA, SAT scores, class rank) for all program applicants; academic indicators (GPA and MCAT scores) for the 159 students who have enrolled in the PHC since its inception in 1994; and UT-PA graduation, medical school matriculation, and eventual career choices for PHC matriculants and applicants with whom the program has maintained contact.
To date, 1,097 students have applied for admission into the PHC. Of these, 318 have been interviewed, 208 have been accepted, and 159 have matriculated into the program (81.7% Mexican American, 10% Asian, 5.7% Caucasian, 1.3% African American, and 1.3% Other Hispanic). Seventy-one students have completed the college portion of the program at UT-PA. Of these, 60 (84.5%) have matriculated into medical school to date (fall 2002). The remaining PHC graduates have entered graduate programs in optometry, public health, and science. Five are teaching biology in South Texas. In May 2002, five PHC students graduated from medical school. Of these, four entered residency programs in Texas, three in primary care fields.
PHC matriculants are strong academically. Most are near the top of their graduating high school classes and have high GPAs. Their SAT scores tend to be considerably higher than average in Texas and the United States. Table 1 summarizes PHC student data from 1994 to 2002.
The first group of students entered the PHC in the fall of 1994. The PHC already has increased the number of Hispanic graduates from U.S. premedical and medical degree programs. To date, 71 PHC students (97% Hispanic) have graduated with their BS degrees. Of these, 60 have entered Texas medical schools. The first PHC cohort of five students graduated from medical school in May 2002. These results are significant in light of the fact that in 1996, only four students from all five South Texas colleges (combined enrollment of close to 30,000 students) were accepted to medical school.
Comparative Outcomes Data
Program faculty at BCM and UT-PA conducted a study to determine whether PHC students from medically underserved communities were more likely to matriculate into medical school than were students with similar academic backgrounds who did not enter the program. All students who interviewed for the PHC from 1994 to 1997 were included in the study. During this time, 464 students applied for admission to the PHC; 153 were interviewed, 103 were accepted, and 84 matriculated. Reflecting the South Texas population, 93% of students who interviewed for the PHC, and 93% of those who matriculated, were Mexican American. Six sevenths of the remaining 7% of the interviewees were Asian and one seventh were Caucasians; five sevenths of the remaining 7% of matriculants were Asian and and two sevenths were Caucasians.
Assuming college entry in the fall semester following high school graduation and completion of a four-year college program, all of these students would have graduated from college and been eligible to apply to medical school and matriculate by 2001. High school GPA, science GPA, and SAT scores were used as indicators of pre-college academic ability. Medical school matriculation was the outcome variable studied. Only the 153 students selected to interview for the program from 1994 to 1997 were included in the analysis. The 311 program applicants who were not selected for an interview were not included in the analysis, since these students generally had lower pre-college academic indicators than those interviewed. PHC matriculants (those who were interviewed, were accepted, and entered the program) were compared with students who were interviewed and were accepted but chose not to attend the PHC and students who were not accepted into the PHC following the interview (see Table 2).
The odds of medical school matriculation was seven times higher for PHC students than for non-PHC students (odds ratio = 7.030). Of the 84 students who entered the PHC between 1994 and 1997, 48 (57%) had gained admission to medical school by the fall of 2001. By comparison, only 11 (16%) of the non-PHC students (those who interviewed for the PHC but did not attend the program) had matriculated into medical school by 2001. A loglinear analysis of the data indicated that the relationship between participation in the PHC and medical school matriculation was statistically significant (Δχ2 (1) = 28.75, p < .0005, CFI = .964).
Because the study groups were not randomly assigned, there could be alternative explanations for the dramatic difference in medical school matriculation rates for PHC versus non-PHC students. For example, it could be argued that those who interviewed but were not selected for the PHC may have had less commitment to medicine, resulting in lower interview scores and elimination from the applicant pool. Likewise, students who were accepted to the PHC but declined admission may not have been as committed to careers in medicine as were those who enrolled in the PHC.
However, the data are strengthened by the fact that all individuals included in the study expressed strong interest in medicine initially, and the groups were statistically similar based on pre-college academic measures. Even when compared only with the stronger of the PHC applicants—those accepted to the PHC who declined admission—PHC participants were much more likely to matriculate to medical school (57% versus 21%; odds ratio = 5.0). The 19 students who were accepted to the PHC but did not matriculate cited various reasons for declining the offer, including better scholarship offers from other colleges (three entered other combined-degree programs), desire to attend a more prestigious university, or desire to attend school further from home. Thus, there is every reason to believe that this group of students was equally motivated to pursue medically-related careers.
Clearly, a follow-up survey of PHC applicants would be valuable in identifying factors related to retention in and attrition from the medical school pathway. However, due to the difficulty of maintaining contact with previous PHC applicants, as well as with students who entered the PHC but withdrew or were dismissed before graduation, only limited, anecdotal information is available. At least 20% of non-PHC students and 24% of PHC participants who did not matriculate into medical school are known to have continued to pursue science and health-related interests, including optometry, podiatry, dentistry, nursing, occupational therapy, communication disorders, public health, basic science research, and science education. These outcomes suggest that a significant portion of students maintained interest in health-related and science-related careers. In addition, since the study followed students only through 2001, it is possible that additional students may apply and be successful in gaining admission to medical school in the future. Some students take more than four years to complete a bachelor's degree or opt to wait a year or two after college graduation before applying to medical school in order to take additional course work or gain additional research experience and take graduate studies to improve their preparation for medical school and increase their competitiveness.
In summary, the study strongly supports the conclusion that the PHC enhances the likelihood that students from South Texas will access medical education. Part of this success must be attributed to the students themselves. The PHC selects motivated, academically qualified students and provides support to maximize their retention in the rigorous academic continuum and their chances of accessing medical education. However, it is implausible to suggest that most of these students would have succeeded without the PHC, given the low retention rates for non-PHC students, the evidence from other studies,6,7,8 and data from South Texas for years predating the PHC.
Indirect Program Influences
In addition to the direct program outcomes discussed above, the PHC appears to have influenced the culture at UT-PA by increasing the number of premedical students at the university overall, as well as the number of UT-PA graduates gaining admission to medical school. Since the PHC was established in 1994, the number of entering freshman at UT-PA declaring themselves as premedical students has more than doubled.9 At the same time, the number of UT-PA graduates matriculating into medical school has increased sevenfold—from four in 1996 to 30 in 2001, including a total of 48 PHC and 35 non-PHC UT-PA students from 1998 (when the first PHC cohort graduated from UT-PA) to 2001.9 These data suggest that the success of the PHC may be encouraging some of the area's stronger students to remain in South Texas and attend UT-PA. Moreover, since the majority of UT-PA graduates who matriculate to medical school are Mexican American, UT-PA has become a leading producer of Mexican American medical students nationally. From 1998 to 2001, 70 Mexican American students from UT-PA matriculated into U.S. medical schools, representing 4.5% of all Mexican American matriculants nationally, second only to The University of Texas at Austin, which produced 72 Mexican American medical school matriculants during the same period.10
The PHC's initial success has been acknowledged by the Texas legislature, which has passed a bill to promote its replication. Specifically, in 2001, the Texas legislature passed the Joint Admission Medical Program (JAMP), Texas Senate Bill 940. Initially funded at $4 million, this initiative will partner Texas's 31 public colleges and universities, several private colleges, and the state's eight medical schools to identify and recruit economically disadvantaged students into JAMP programs. Each year, 128 college freshmen will be selected for an eight-year BS–MD program that follows the PHC format almost exactly.
THE FUTURE POTENTIAL
By establishing an honors college at UT-PA that has garnered statewide and national recognition, the PHC has dramatically increased the number of students from South Texas accessing medical education. Ultimately, the success of the PHC will be evaluated by the number of graduates who successfully complete medical school and residency programs and return to South Texas to practice. The majority of students currently in medical school continue to express a commitment and desire to return to their hometowns to practice. Assuming that current trends continue, the PHC has the potential to significantly expand the number of physicians and other health care providers serving the medically underserved communities of South Texas (by producing ten to 15 medical school graduates per year).
The PHC demonstrates that a partnership between a large predominantly Hispanic college and a private medical school can begin to address problems associated with the under-representation of South Texas students in medical education (and thereby address health care needs of this underserved region of Texas). The PHC has been able to attract considerable financial support from major external sponsors: the U.S. Department of Health and Human Services (faculty salary support), The Robert Wood Johnson Foundation (for summer programs), and the Houston Endowment (for college tuition and fees, program coordination, and recruitment activities at South Texas high schools). Additionally, physicians throughout South Texas have been eager to serve as mentors for PHC students. They have generously provided preceptor sites for students during both the college years and the medical school years and have even begun a scholarship fund for PHC students. This involvement is crucial in helping students to establish even stronger personal bonds to the region and encouraging them to return there to practice after graduation.
The PHC continues to mature and now has a full complement of students, spanning from college freshmen to first-year medical residents. Since the program began, BCM has provided funding directly to UT-PA for a faculty coordinator, student tutoring, and general office support. This allows BCM to have direct daily contact with college-level PHC students and rapidly identify and resolve problems as they arise. Additionally, the PHC provides an important model for research to evaluate programs designed to create pathways from high school to medical school. The results of such studies will benefit others in Texas and elsewhere who may implement similar initiatives.