Norris, Thomas E. MD; House, Peter MHA; Schaad, Doug PhD; Mas, Jennifer MPH; Kelday, Joan M. MSJ
Rural and urban underserved populations in the United States should have access to the same quality health care that is available in urban and suburban settings for people with health insurance. Yet, at present, there are substantial and increasing differences in rural and urban health care, especially in access to health care for underserved populations.1 General physician supply increased overall between 1980 and 2000, but rural areas are not sharing the same rate of increase as urban areas.2–4 Medical education and residency have not emphasized preparation for rural practice. As generalist physicians in rural areas retire, recruitment and retention of replacement physicians is not occurring at a rate to support the workforce vacancies.5
Over 50 million people, or 20% of the U.S. population, live in rural areas. Logically, 20% of U.S. physicians should practice in these rural areas, but only 9% of U.S. physicians do so. One could argue that it is not important to have access to some specialties in rural locales, but accepting this argument leads to a slippery slope away from equity in health care quality and access for rural people. At the very least, rural populations should have equal access to primary care physicians and to commonly needed secondary specialties for both routine health matters and emergencies. In large metropolitan areas, one finds 300 physicians per 100,000 residents; yet if one studies small rural areas, one only finds 75 physicians per 100,000 residents—one fourth the provider density found in cities. Although the supply of physicians has increased since World War II, rural areas have not attracted their “fair share” of the proliferation.3 This disparity in the density of the rural versus the urban physician workforce has worsened steadily.
As a result of this shortfall in rural providers, 22 million people in the United States now live in federally designated rural Health Professions Shortage Areas with less than one primary care physician per 3,500 people.6 These individuals, who comprise 5% to 10% of the U.S. population, have inferior access to medical care relative to the urban insured or they may lack access altogether. Similar provider shortages face the urban poor.
The key to addressing some of the problems of rural and urban underserved patients lies in “fixing” the workforce. This correction will require more providers who are committed to the care of these populations. Because of the chronically short-staffed rural and urban practices for the underserved, health care providers will need to be dedicated to working in teams. The Student Providers Aspiring to Rural and Underserved Experiences (SPARX) program at the University of Washington endeavors to imbue the training of health care providers with these characteristics.
The University of Washington School of Medicine and Health Science Schools
The University of Washington School of Medicine (UWSOM) is a regional medical school that annually admits medical students from Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) in a 32-year-old medical education partnership called the WWAMI Program.7 From WWAMI’s inception in 1971, the medical school assumed a responsibility to prepare students for practice in its largely rural region. The mission statement of the school reflects this goal: “The school acknowledges a special responsibility to the people in the states of Washington, Wyoming, Alaska, Montana, and Idaho who have joined with it in a unique regional partnership.” Since 1971, the school has established more than 75 clinical training sites across the region and introduced programs and incentives to encourage students to enter rural practice: the Rural/Underserved Observation Experience (a “shadowing” opportunity for newly accepted students); Rural/Underserved Opportunities Program (a four-week to six-week preceptorship for second-year students with rural practitioners in towns of fewer than 9,000 people); and WWAMI Rural Integrated Training Experience (a six-month multispecialty rural clerkship for third-year students). Combined, these programs demonstrate UWSOM’s commitment to training physicians for rural (and urban) practice for the underserved.
In 1985, UWSOM offered its support for other health professions in rural areas by creating of the interprofessional WWAMI Area Health Education Center (AHEC) program. Today this program has six centers in the five WWAMI states, as well as a program office based at the University of Washington’s Seattle campus. The program recruits people (especially members of rural and minority groups) into the health professions, arranges training placements for University of Washington medical students in Rural/Underserved Observation Experience and Rural/Underserved Opportunities programs, provides local continuing education and faculty development sessions, helps recruit practitioners to underserved areas, works with leaders in rural communities to help strengthen their health care systems, and promotes use of telecommunications in training and patient care. Despite these and other efforts in the northwestern United States and by other AHECs nationally, a maldistribution of physicians and other health professionals persists in rural areas and among the urban underserved.3
The rural and the urban community clinic traditions of team-practice among health care professionals underscore the importance of training medical students and other health professions students to work effectively in teams. Because they are organized into schools and departments, academic medical centers are often ill prepared to train students for team practice. Factors contributing to this situation include the traditional focus of each training program on its own discipline, as well as limited infrastructure and funding for interdisciplinary courses and activities involving faculty and students from multiple schools and programs.8
The SPARX Program
History and Purpose
In 1994, in an attempt to address these problems, UWSOM’s Office of Regional Affairs and Rural Health sponsored a series of meetings that shaped the first activities of a multidisciplinary student program that came to be called SPARX (Student Providers Aspiring to Rural and Underserved Experiences). Unlike programs providing educational placements away from UWSOM in Seattle, the SPARX program concentrates on the students from medicine and other health science schools during the time spent in their educational programs in Seattle. Many students come to UWSOM intending to return to a rural setting for practice, bringing with them an aspiration to spend their professional careers working with the underserved. While in Seattle at the academic medical center, students sometimes stray from these goals, focusing instead on specialty practice or lifestyle choices, such as scope of practice and call coverage, that lead to an urban practice location.
The goal of the SPARX program is to provide health science students with a wide variety of extracurricular activities, including exposure to successful practitioners who serve rural and urban underserved populations, which fosters and maintains their interests in serving these populations while they are in Seattle. Although the activities are voluntary and not part of the required curriculum, the schools of health science encourage participation.
The Early Years
In an effort to bridge the communications and collaboration gaps between students in the various health sciences schools, UWSOM invited the five other health sciences schools (Dentistry, Nursing, Pharmacy, Public Health, and Social Work) to participate in development of the SPARX program as an interprofessional program. A SPARX steering committee, composed of faculty and staff members in the various health professions programs, established a common vision for SPARX and created an infrastructure to link the schools around the project. In 1996, the University of Washington/WWAMI AHEC program assumed responsibility for administering and funding the SPARX program.
Recognizing the importance of grassroots leadership for rural programs, the faculty worked to create a situation in which the planning and strategic direction setting for the SPARX program came largely from health science students themselves. Beginning in 1994, these empowered students formed the foundation and created the direction for future SPARX activities. A database of all interested students in medicine, nursing, and public health was compiled and served as a means to communicate more broadly among disciplines. Emphasis was placed on networking among the different disciplines and exploring methods to promote and preserve interest in rural and underserved experiences and practices.
In 1996, based on data gathered from a student-interest questionnaire sent to all 850 matriculating and second-year students at UWSOM, and on input from student meetings, SPARX’s menu of activities was expanded. Results of the questionnaire indicated that 169 (20%) of the students were interested in practicing among the rural and urban underserved. The students identified areas of particular interest, including health care issues of rural residents, urban underserved, battered women, unwed mothers, and HIV/AIDS populations. Attendance at SPARX events increased from almost 100 students in 1995–96 to more than 300 in 1996–97.
SPARX today is an interprofessional, student-operated AHEC, and faculty-supported program consisting of a wide range of activities designed to maintain student interest in rural health care. The WWAMI AHEC advisory board serves as the steering committee for SPARX, providing oversight of planning, activities, and direction. The membership of the committee represents multiple health professions and serves as a liaison among the AHEC, the students, and the various disciplines. Steering committee members are responsible for e-mails that market SPARX activities to students in their schools, and for distributing SPARX material to incoming students and attending SPARX events throughout the year. An Internet listserve and Web site are maintained to further inform students about upcoming events and to serve as resources for information on the different disciplines.
Although the SPARX Program has expanded activities since the years of early student discussions, it has preserved two main goals: to create networks and links among students in the different disciplines, and to promote and preserve interest in rural and underserved experiences and practices. The SPARX venue continues to grow by accommodating ever-expanding areas of student interest. As one physician assistant student said, “Meeting students from other disciplines allowed me to feel connected and helped me fight the sense of isolation that can result from a grinding didactic schedule.”
Forums and Seminars
An idea taken from the original student discussions, forums, and seminars remain an integral component of the SPARX program. They are held on varying days and times to accommodate different health sciences schools’ schedules and usually include pizza and refreshments. Activities are often scheduled to overlap with rural practitioners’ visits to Seattle and the University of Washington. A question period is held at each forum to encourage dialogue between students and presenters. Topics are based on student feedback. Inspirational speakers are selected to nurture the aspirations of the students to have careers in rural and other underserved settings. As a second-year medical student said, “The forums, although they come after a long day of studying, serve to inspire and refresh the soul. I always leave more excited about the physician I may become.” Recent speakers have ranged from state officials and panels of practitioners to discussion groups concerning communities facing health care challenges.
Multicultural Competency and Interprofessional Dialogue
Based on the emphasis on working with underserved and in rural communities, the SPARX program is committed to training interprofessional groups of students to collaborate in a team setting while demonstrating competence in working with diverse cultures. Although each school trains students in cultural competency, little has been done to foster an interprofessional approach to cultural competency. In 2001–02, a collaborative effort between the SPARX program and several other campus-based groups resulted in a multicultural competency-training project.
To gain first hand understanding of rural communities and urban health facilities for the underserved, SPARX arranges field trips to medically underserved communities. As a result, students have identified concerns about the isolation of health care providers working in rural areas. The field trips allow the students to interact with health professionals in their home settings and to appreciate the reality of practicing in these areas. By visiting communities, students develop a sense of the connections within the rural communities and their health systems. As a second-year medical student said, “The field trips give an even larger snap shot into real lives of rural/underserved providers. I think these are invaluable because they allow me to briefly ‘try on a professional lifestyle’ and see if it fits.”
An awareness and understanding of these connections is of critical importance for students who are considering primary care careers. In its seminal study on primary care, the Institute of Medicine felt that these connections were key to the discipline. These connections are illustrated in Figure 1. 9
Community Service Projects
The SPARX program increasingly integrates community service projects into its inventory of student activities. Projects enable students to work in teams toward a common goal, such as distributing clothing to migrant farm workers or talking to kids about health. These projects provide a real-life example of the skills needed to work in teams in rural and underserved settings. SPARX projects always involve two or more disciplines, address rural or underserved issues, and relate to patient care, public health, or community service. Although students usually choose their own projects, the SPARX program administratively and financially supports their efforts. Examples of community service projects conducted by SPARX students include:
Children’s Health Day, Walla Walla, Washington
A team of interprofessional students attend the annual Children’s Health Day to screen and refer youth to local agencies and to promote positive images of health professionals for the largely Native American and Hispanic attendees.
Othello and Mattawa, Washington project
A team of interprofessional students conduct screenings in coordination with the local community health centers at their annual health fair in a small town about 150 miles from Seattle. As part of the project, the students hold a clothing drive on campus in spring and distribute the contributions during their time in Othello and Mattawa. Sponsorship is also integrated to provide outreach to migrant farm workers in the fields.
Campus–Community employment collaboration
SPARX hosts the annual Rural and Underserved Opportunities Fair for health sciences students interested in learning more about employment opportunities in rural and/or urban medically underserved areas. Over 15 agencies, including rural hospitals and local and rural community health centers, have exhibited employment and area information to health sciences students on campus.
In 1999, SPARX developed its first urban underserved clinical expansion with the creation of the Safe Links project. Safe Links provides competent, team-based medical services to homeless youth on the streets of Seattle using a motor home equipped as an examination room. Safe Links is a clinical practice site for the schools of medicine and nursing, enabling preceptors, and medical, nurse practitioner, and physician assistant students enrolled in SPARX to serve as volunteers. The Safe Links collaboration project improves medical information gathering and care delivery skills of the students and models a collaborative, interprofessional approach to improve the delivery of health care services to at-risk such as homeless youth. As a second-year medical student said,“[Safe Links] reinforced my desire to work with youth in the future, especially youth who are so underserved.” A public health student agreed: “[Safe Links] is valuable personally and professionally to me. To spend time with different types of people with different priorities, helps me keep my life in perspective and constantly challenges me to confront stereotypes and keep an open mind.”
Participation in SPARX
After an initial strong start, participation in SPARX has remained robust, and the program’s activities, as well as the diversity of its student participants, continue to grow (see Figure 2). In the words of a senior undergraduate student, “SPARX is a remarkable program.…To learn about the needs of individuals in underserved conditions and settings was not only humbling but inspirational in that it helped me further strengthen my commitment to medicine.”
In 1997, the SPARX Participation Award for extraordinary participation was created, allowing students to earn a certificate by accumulating points through attendance. Seventeen students received the award that first year. A copy of the certificate, along with a letter, is sent to dean of the student’s school. The certificate assists in building a resume that will help support applications to service-contingent loan repayment programs. Since 1997, students in medicine, nursing, pharmacy, physician assistant, dentistry, health informatics, public health, physical therapy, and undergraduates have received certificates. The certificate program has worked well to increase participation in SPARX. The percentage who attended more than three events during the year increased from 8% in 1996 to 34% in 1999 as the program gained recognition among students and communication improved through use of the listserve and Web site.
SPARX Expansion to the Five-State WWAMI Region
The WWAMI program consists of six first-year medical student teaching sites located on state university campuses in Washington, Wyoming, Alaska, Montana, and Idaho. Since 2001, the SPARX model has expanded regionally. Each of the six WWAMI AHECs received funding to create programs on local campuses, similar to the ones sponsored at the University of Washington. This expansion ensures that all WWAMI first-year medical students will have the opportunity to become part of SPARX.
Outcomes: Influence of SPARX on Student Career Selection
An e-mail survey conduced in winter 1998 queried 150 students on the SPARX list serve who had attended one or more SPARX events in the previous five months to assess SPARX’s influence for them. Thirty-eight students (25%) responded. Twenty-six respondents said they had considered rural or urban underserved practice before entering professional training. Twenty-four felt that SPARX had increased their interest in rural practice “quite a bit” or “very much,” and 13 positively rated SPARX’s influence on their interest in urban underserved practice. Twenty-five said that SPARX had influenced their understanding of other health professions “quite a bit” or “very much.”
Medical Student Choice of Specialty
Since the inception of the SPARX program, UWSOM has had six cohorts of students (n = 886) participate in the National Residency Matching Program. The first cohort of SPARX students graduated in 1998 and had only five students. Concomitant with the growth of the program, the subsequent five cohorts of graduates had 211 SPARX participants. In essence, nearly 25% of recent UWSOM graduates have participated in the SPARX program.
In reviewing the results of the Match, we constructed a two-by-two table that arrayed SPARX participation with a primary care match (family medicine, general internal medicine, and pediatrics). Participation within the SPARX program was significantly associated with a primary care match (corrected χ2, 9.99; p < .01) Sixty-two percent of the SPARX participants matched in primary care while only 50% of non-SPARX participants matched in primary care. For SPARX participants the proportions matching in each of the three primary care areas was 27% for family medicine, 24% for internal medicine, and 11% for pediatrics.
Although it is still too early to judge the ultimate success of the SPARX program in stimulating graduates to provide health care services in underserved settings, these preliminary graduate medical education trajectories are encouraging. As these former SPARX participants enter their medical practices, we anticipate that a disproportionate number will enter rural and underserved practices. At this point, the data simply aren’t available to confirm or reject this hypothesis.
A significant number of health professions students value the SPARX voluntary multidisciplinary program offered at the University of Washington. The program has established an interschool infrastructure that promotes collaboration and provides experiences supporting students’ interest in practice among the underserved.
SPARX is now part of the UWSOM and WWAMI fabric of health sciences education, with the fall kick-off for the program regularly drawing over 100 students. Students often hear about SPARX before they matriculate (via mailings from the schools and more effectively through word of mouth) and they are eager to participate in the activities.
The SPARX program could be easily replicated on other health sciences campuses. A key to the success of SPARX has been our ability to use AHEC funds for support. In addition to providing a budget for direct expenses, like field trips and food for evening forums, AHEC has funded a half-time coordinator to assist in scheduling events and recruiting students. Because AHEC programs are present on many medical school campuses, similar support could be provided to assist in creating SPARX programs elsewhere. Although the core of our success is based on the commitment, creativity, intelligence, and charisma of the young professionals who have run the program, a small budget, combined with senior faculty support and guidance, has also been a critical attribute.