Editor's Note: A Commentary on this article appears on page 1121 of this issue.
The growing diversity of the American population is one of its greatest assets, and health care disparity is one of its greatest challenges. Population projections for the United States predict an increase of nearly 30% from 2000 to 2030.1 The U.S. Latino population has experienced considerable growth, increasing from 22 million (9%) in 1990 to an estimated 42.7 million (14.5%) in 2005, and it is expected to continue growing.2 California, Texas, and, more recently, New Mexico have emerging majority Latino populations. Coinciding with these increases are predicted physician shortages nationally3 and significant health care disparities for Latinos,4 bringing to light the undeniable need for a physician workforce capable of caring for the growing Latino community.5
The Program in Medical Education for the Latino Community (PRIME-LC) at the University of California–Irvine (UCI) School of Medicine was designed to train physicians in linguistic skills and cultural understanding and to enable them not only to provide health care to Latino patients but, also, to become leaders in health care serving the Latino community.
At the onset of this project, we realized we were proposing a radically different type of program—one designed to address the health care needs of a specific ethnic group. Although initially this may seem very radical, historically medicine has developed programs to address the needs of a special population when the customary program proved unable. Specialties such as pediatrics, obstetrics–gynecology, and geriatrics were developed to enhance care for these populations, and the Veteran's Administration system was created to better address the health care needs of veterans. Our program may seem to be a departure from the norm, but, in reality, it is no different from previous successful processes. Latinos are far less likely to report having health insurance than are other population groups,6 but it is important to note that even if health insurance were provided to the entire community, health disparities would remain. The lack of providers with linguistic and cultural expertise in the present health care system renders it unable able to address those needs. It cannot be overemphasized that language is just one of the barriers; cultural barriers are equally important. Understanding cultural backgrounds allows us to adapt medical knowledge to the special needs of a particular patient. It enables patients to understand the seriousness of their conditions and the importance of follow-up, it encourages their adherence to medical and dietary regimens, decreases litigation, and, overall, it improves the communication and comprehension between provider and patient. This direct communication cannot be replicated or replaced by translators or interpreters.
To enact a dramatically different program in a rather traditional university is, of course, a challenge. We understood that to be successful we would have to gather support from diverse directions—internally from our academic colleagues and externally from government, professional, and community organizations, as well as from the community at large. Our academic colleagues needed reassurance that PRIME-LC was a high-quality educational program and not a backdoor entry into medical school. The program was presented to various faculty groups and the school of medicine's academic senate executive committee. Some faculty meetings were attended by UCI's chancellor and executive vice chancellor. During these meetings, we were able to emphasize the high quality of the program, evidenced by the fact that PRIME-LC uses the same admission criteria as the rest of the school of medicine and also has additional requirements. PRIME-LC students graduate with two degrees, and this was further evidence of the academic rigor of the program. After approval from the UCI campus, we met with the University of California Office of the President, specifically with then Vice President for Health Sciences Dr. Michael Drake, who became a strong advocate and enthusiastic supporter of the program. PRIME-LC also had support of the previous and present presidents of the University of California system. When developing the program's curriculum and requirements, we consulted community, government, and professional organizations in an attempt to identify the expected characteristics of graduates from this program who would be able to address the health care needs of the Latino community. Among the organizations consulted were the National Hispanic Medical Association, California Latino Medical Association, Latino Health Access, Office of Statewide Health Planning and Development, and grassroots organizations. Testimony on the importance of the program was presented to the Sullivan commission. We also had the opportunity to discuss the program with members of the California state legislature and the chair of the Latino Caucus (Assemblyman Marco Firebaugh [deceased]), who was a determined force in obtaining appropriate funding for the program. Another presentation was made, under the auspices of the University of California Sacramento Center in Sacramento, to allow legislators and their staff an opportunity to become familiar with the program. An advisory board, comprising active members of the Latino community and academicians from within and outside UCI, was formed. This committee proved to be a key element in our success, especially during the early years of developing and implementing the program. After three years of preparation, PRIME-LC was finally launched in 2004.
Assessing the Needs of the Latino Community
We determined desirable characteristics and expected attitudes of health care providers by consulting with community groups and by the personal experience of one of the authors (A.M.). Our investigation revealed that the typical high school and college education does not provide students with a reasonable understanding of the geography and history of Latin America. In reference to language, we realized very early that being of Latino descent does not make a student proficient in Spanish. Although Latino students generally have good cultural understanding, they may not have the linguistic ability to perform the duties of a physician in a Spanish monolingual population. We felt that it was impossible to teach students a second language in addition to addressing the medical school curriculum, but we also recognized the need for students to be able to communicate fluently with Latino patients. Our compromise was to require applicants to have a basic knowledge and command of the Spanish language. This would enable students, with additional language training, to develop the expected linguistic skills quickly.
In addition to language skills, we promptly recognized that several other factors would be critical elements in PRIME-LC training. Specifically, an understanding of Latino culture, knowledge of the geography and history of Latin America, understanding Latino population migration patterns into the United States (especially into California), and awareness and understanding of immigration and documentation-status legal issues. Moreover, it was critical to emphasize issues such as leadership, activism, and advocacy for the impact of our graduates to go beyond the individual patient to the greater Latino population. It was also decided that the curriculum would include specific knowledge related to medical conditions prevalent in Latinos.
Goals of PRIME-LC
The program was developed with two goals: (1) to provide the Latino community with culturally sensitive, Spanish-speaking physicians who are well aware of medical and social conditions prevalent among Latinos, and (2) to provide the Latino community with physicians who have a broader understanding of community medicine and who are well versed in advocacy and able to become leaders within and outside the Latino community, to better serve the entire community.
We also decided that the best way to sharpen linguistic skills and to emphasize cultural, social, historical, and geographical issues was through an immersion program. Two questions followed: where and when to place this experience. We decided the experience should be at the beginning of the students' medical training, to allow them to implement and integrate new skills into their daily activities quickly. The where proved to be a more complicated issue. Any type of immersion program requires participants to live the experience—“walk the walk and talk the talk.” We finally decided that this part of the training would take place in Cuernavaca, Mexico, in the state of Morelos. We selected this city because of the willingness of their health officials to work with us, the special relationship developed with the secretary of health of the state of Morelos, the proximity to Mexico City, and the presence of a well-established language institute (Universidad Internacional) with significant immersion program experience.
During the inaugural PRIME-LC immersion experience, the students were housed with Mexican families who did not speak English. We tried to house only two students per family, and all the students' meals and extracurricular activities took place with the family. Classes were held at the university, and course work included Latin American culture, history, and geography. Students took several field trips to selected historical and cultural sites, including the world-renowned Museum of Anthropology in Mexico City. Fifteen physicians (13 preceptors and 2 coordinators) participated in the project as instructors. Each student was assigned to spend time with two physicians from differing facilities, areas of the city, and demographics. Students shadowed these physicians through their daily activities, observing how to take medical histories in Spanish and practicing their Spanish skills. They had ample time to interact with patients and to inquire about their conditions. A recognition dinner was held at the end of the Mexican experience as an opportunity to congratulate the students and to specially thank the instructors for their participation.
All initial planning for PRIME-LC, including curriculum development and piloting of the program, was funded through foundation support from The California Endowment and Unihealth. Although this generous support allowed us to launch our program, the survival of PRIME-LC was based on the availability of permanent funding. Resources in the University of California system are allocated according to the number of students enrolled, and the increase in class size at UCI School of Medicine that would come with the establishment of PRIME-LC was an absolute necessity for the long-term survival of our program. We received authorization to increase the medical school class at UCI from 92 to 100 in the first year and to 104 in subsequent years. When fully implemented (as a five-year, dual-degree program), we will have 60 PRIME-LC students at the school of medicine. This was the first increase in the number of students at any of the five UC medical schools (Davis, Irvine, Los Angeles, San Diego, and San Francisco) since 1965, and it has given permanence to PRIME-LC. Additionally, to meet Liaison Committee for Medical Education requirements, we must increase the program's budget to match the increase in class size.
In addition to the existing school of medicine admissions committee, a special committee has been formed to consider applicants to the PRIME-LC. This committee consists of faculty from the school of medicine, faculty from the school of social sciences (department of Chicano/Latino studies), and current PRIME-LC class representatives. Our codirectors (J.R. and C.V.) are also members of this committee. All faculty serving on this committee were directly involved with the development of PRIME-LC and are familiar with the goals and objectives of the program. Students interested in our program are not necessarily Latino; actually, most of our applicants are not. There are five steps in the selection process:
1. Applicants must meet all requirements for admission to the UCI School of Medicine.
2. Applicants must have gained admission to the UCI School of Medicine before they are considered for PRIME-LC.
3. Applicants must complete an additional admission process, including an interview conducted in Spanish. Applicants must be able to demonstrate a basic ability in conversational Spanish.
4. Applicants must demonstrate relevant interest and life experience. All PRIME-LC students have a history of work with underserved populations and have demonstrated a commitment to caring for the underserved and, specifically, for Latinos. Many of them have had significant experience serving underserved communities in Latin America.
5. All accepted applicants are invited to a special dinner meeting with the director of the PRIME-LC. Most faculty also attend. This is an opportunity for the director to express, once again, the values of the program and expectations of the faculty and administration. Students who are hesitant in any way about accepting admission to the program are asked to reconsider their initial decision to apply, to allow timely acceptance of applicants on the wait list. Every year, one or two students have decided not to go forward after this event.
The regular PRIME-LC curriculum is funded by university-allocated resources, as discussed above. All additional (not part of the regular program) expenses related to PRIME-LC, including the five-week summer immersion program in Mexico, are covered by the program. Scholarships are provided in accordance with need.
PRIME-LC students are enrolled in June—earlier than the other first-year medical students are enrolled—to allow for their immersion experience in Mexico. The length of this experience was determined by the amount of time available between their completion of undergraduate studies and beginning medical school course work. Initially, this was a six-week period that, because of an earlier medical school start date, was subsequently reduced to five weeks. Students return from Mexico a few days before the beginning of their first-year classes.
The PRIME-LC curriculum comprises six components. First are the unchanged traditional medical school courses such as anatomy, medical biochemistry, etc. Other courses were modified to include content addressing the PRIME-LC goals, and these are the second curricular component. For example, the PRIME-LC Patient–Doctor course series and problem-based learning sessions integrate material specific to treating Latino patients. Third, new courses have been specifically designed for PRIME-LC that, in addition to the material taught during the immersion experience, include courses managed by the department of Chicano/Latino studies in the school of social sciences. All PRIME-LC students will graduate with both the MD degree and a master degree, and the fourth component of the curriculum includes courses relating to the graduate-degree portion of the program. To date, most PRIME-LC students have declared interest in the master of public health, master of public policy, and master of business administration (with special emphasis in not-for-profit) degrees. Fifth, electives focusing on the PRIME-LC objectives are continuing to be developed, and students have already taken advantage of some of these opportunities. Practical experiences working with California legislators, border experiences, grassroots organizations, and international experiences are examples of electives that have proven popular among the students. The sixth component of the curriculum is scheduled extracurricular activities, such as student gatherings with a moderator to discuss books and other material. Reading material is assigned in conjunction with these discussions—one of the books extensively used is La Nueva California by Dr. David Hayes-Bautista.7 In addition, leaders from health care and other disciplines are invited to these sessions as guest speakers. Heads of industry, managers of philanthropic foundations, scholars in Latino issues, and representatives from community-based organizations are examples of those who have participated. These meetings also serve as an opportunity for students to strengthen the bond previously established during their early experiences together.
To gain the recognition for the rigor of PRIME-LC that we were seeking, we have developed a thorough evaluation plan for the program. We begin gathering information for the purpose of evaluating the program at enrollment and prematriculation, and this continues throughout medical school, residency training, and beyond (Table 1). Student information at the individual and aggregate levels, as well as data common to all medical students, and some that are unique to PRIME-LC students, are collected. As part of this evaluation, we developed end points that have been and will continue to be monitored:
1. Maintenance of an acceptable number of applicants applying to PRIME-LC (Table 2).
2. PRIME-LC students' academic success in the standard curriculum. This is not a small accomplishment when taking into consideration the extraordinary number of additional, nontraditional activities required of these students.
3. Retention of students in the school of medicine.
4. Retention of students in PRIME-LC.
5. Involvement of students in extracurricular activities related to the goals of PRIME-LC.
6. Students' successful completion of all licensure examinations.
7. Students' graduation from medical school.
8. Graduate medical education (GME) in a specialty and program that are congruent with PRIME-LC goals.
9. Placement of clinical practices in areas with high percentages of Latinos.
10. Percentage of Latino patients in the individual practices. Our expectation is that these students will see a greater percentage of Latino patients than will other physicians in their area. (We have developed the methodology to address 9 and 10.5
11. PRIME-LC leadership participation in government and professional associations.
12. Attendance at continuing medical education (CME) activities that focus on health care disparities and health issues specifically related to the Latino community.
Patient satisfaction will be an important measure of the program's success in meeting the goal of providing culturally sensitive, linguistically competent physicians for Latino patients. An integral part of the evaluation plan will be administering patient surveys to ascertain their level of satisfaction, comparing PRIME-LC and non-PRIME-LC students and, later, PRIME-LC and non-PRIME-LC graduates.
Results of the PRIME-LC Experience
After students come back from Cuernavaca, a debriefing meeting takes place. Present at the meeting are all students, the director of the program, the associate deans for basic science and clinical curricula, faculty from the department of Chicano/Latino studies, and the PRIME-LC codirectors. The meeting focuses on successful elements of the program and possible opportunities for improvement. Students must also complete a short essay describing their immersion experience. The feedback from the students has proven invaluable and is used to improve this experience. We were obviously working in uncharted territory; nevertheless, relatively few changes have been made during the last three years, exemplifying overall acceptance of the program. One positive outcome has been unexpected, yet consistent during the last three years. This is the bond developed among the PRIME-LC students. Students emerge from this experience as a single unit—they know each other well and have learned to rely on and support each other. The degree of support offered from one student to another, in the experience of one of the authors (A.M.), is unparalleled. This is particularly gratifying, and we expect that these students will continue their relationships for the rest of their professional careers. Efforts were also made to bring students from different class years together. These links are usually focused around a subject of common interest. Some of the issues discussed have been legal aspects of immigration, and history of the Latino presence in California.
Additionally, students are exposed to leaders from outside the Hispanic community. We decided that building leadership skills would be facilitated by inviting distinguished, exemplary leaders from the community to informal extracurricular sessions and by encouraging discussion of issues relative to health care and Latino culture between these individuals and the students.
This early in the implementation of PRIME-LC, the data we have collected address only initial outcomes. The percentage of applicants to the program has continued to increase (Table 2). All PRIME-LC students accepted to date remain in good academic standing, and there has been no attrition from medical school or the program. All PRIME-LC students from the present fourth-year class (first group of PRIME-LC students) have passed Step 1 of the USMLE on their first attempt. The PRIME-LC students have been involved in remarkable extracurricular activities, very often demonstrating strong leadership skills (Table 3).
The introduction of this program has resulted in unforeseen outcomes. PRIME-LC students have initiated discussion of cultural issues with their non-PRIME-LC classmates, thereby increasing the awareness of Latino issues of the entire medical school class. There has been consistent interest from the regular class to participate in PRIME-LC activities, such as the Medical Spanish course and experiences abroad. Additionally, the PRIME model has been extended to the four other medical schools in the UC system (Davis, Los Angeles, San Diego, and San Francisco), although the only program to focus on a specific ethnic group continues to be the UCI program (Latino Community). Areas of focus for the other PRIME programs include rural health (UC Davis), health equity/disparity (UC San Diego), and urban health (UC San Francisco).
The program is not designed to increase the pool of UCI applicants with values and skills compatible with the PRIME-LC. This is a societal issue that cannot be addressed at UCI alone—it requires nationwide focus. The almost exclusive reliance by most medical schools on GPA and MCAT scores plays against this change of attitude. As mentioned by Dr. Jordan Cohen, past president of the Association of American Medical Colleges, we need to examine a student's values first and then ascertain his or her ability to meet the rigors of the medical school curriculum.8
Future PRIME-LC Programs
Although PRIME-LC currently focuses on undergraduate medical education, the program was designed as a continuum from medical school, to GME, to CME.
We again conducted an assessment of GME requirements, primarily using community resources. We found that there is a need for physicians who are competent to serve in Latino communities in almost every discipline. However, for several reasons, the specialties that seem to have the most need are family medicine, pediatrics, general internal medicine, psychiatry, emergency medicine, and obstetrics–gynecology. There is a shortage of Latino-competent physicians in all primary care disciplines. Furthermore, there is a need to maintain an appropriate number of primary care physicians in regional centers and community clinics. It is very difficult, if not impossible, to perform appropriate psychoanalysis through interpreters, and there is an extreme shortage of psychiatrists who are able to care for Latino patients. Unfortunately, emergency rooms are often the entry point for a large number of Latino patients. Finally, obstetrics–gynecology was selected as a result of the large delay documented for Latino women receiving obstetrical care.9 We acknowledge that there are needs in many other disciplines, but these six seem to be where need is the greatest.
At UCI, we have received agreements for PRIME-LC from residency programs in these specialties. A significant amount of time during these GME programs will be dedicated to reinforcing the PRIME-LC goals. Monthly meetings will take place among all graduates residing in the vicinity of UCI, and yearly meetings will be held to collect feedback and discuss potential changes to the program. The above residency programs have also given their reassurances that PRIME-LC graduates will be given special consideration for entry into their programs.
Although it is too early to start designing CME activities for our graduates, we plan to provide all CME hours required to maintain a medical license in California through this program.
Thinking beyond UCI
Finally, PRIME-LC must be placed within the context of predicted shortages of physicians in the United States (a result of the projected increase in the general population) and, more specifically, within the context of a growing Latino population and increase in the number of Latino immigrants nationwide. Planning is especially important in states with Latino populations that are expected to grow significantly (e.g., California, Texas, and Florida),1 where shortages of culturally and linguistically competent physicians could be substantial. As most medical schools prepare to increase their output, PRIME-LC-like programs that address society's special needs deserve serious consideration.
The authors gratefully acknowledge the assistance of the UCI Department of Chicano/Latino Studies and all members of the PRIME-LC Advisory Board. They also wish to extend their appreciation to then University of California Vice President for Health Sciences, and now Chancellor at UCI, Dr. Michael Drake. This program would not have been possible without his support and enthusiasm. This project was supported by generous grants from The California Endowment and Unihealth.