Editor's Note: A Commentary on this article appears on page 1121 of this issue.
The University of New Mexico (UNM) School of Medicine is a publicly funded medical school in a rural state with a commitment to family medicine and to excellence in rural medicine.1 With 32 of New Mexico's 33 counties federally designated as complete or partial Medically Underserved Areas and/or Health Professions Shortage Areas, the UNM School of Medicine's mission to train physicians to practice medicine in areas of New Mexico with the greatest need2 is a major one.
To an important degree, this mission is being fulfilled. One third of the licensed physicians in the state are graduates of the UNM School of Medicine or its residency programs; alumni practice in 29 of the 33 New Mexico counties.3 A cross-sectional study of the 317 graduates of the UNM-affiliated family medicine residencies from 1974 through 2004 demonstrated success in producing graduates with a long-term commitment to practice in New Mexico: 35.4% of ethnic minority graduates were in rural and 44.6% in urban New Mexico practices (compared with 27.6% and 29.9% of nonminority graduates).4 One striking finding of this study was that 84% of physicians who were graduates of both the school of medicine and one of its rural family medicine residencies entered long-term practice in rural New Mexico.
Yet, there is still a critical shortage of physicians in rural, underserved New Mexico. In this article, we describe one of the UNM School of Medicine's new approaches to addressing this problem: the combined BA/MD degree program, which will expand the medical school class from 75 students to 100 in the fall of 2010. The intent is for the program to have the kind of sustained success that has been accomplished by the Jefferson Medical College's Physician Shortage Area Program, which reports an eightfold increase in recruitment and long-term (11–16 years) retention of physicians for rural practice,5 and the combined-degree program of the University of Missouri–Kansas City School of Medicine.6
The UNM School of Medicine and College of Arts & Sciences developed the BA/MD program in partnership to expand opportunities in medical education to New Mexico students, especially those from rural and underserved minority communities, which comprise a little more than half of New Mexico's population (43.4% Hispano/Latino, 10.2% Native American, and 2.4% African American). Faculty developed the UNM program during three years; the program's design was based in part on that of the combined-degree program of the University of Missouri–Kansas City, which has been successful for three decades.6 The UNM faculty used an evidence-based process to address the factors that the literature indicates are those that influence students to practice in rural and underserved communities and factors that promote minority student success. These seven factors are ethnicity, growing up in a rural community, curriculum design, specialized academic advising and tutoring, scholarships, mentoring from community role models, and longitudinal experiences in rural and underserved practice settings.7
The UNM combined BA/MD degree program, which began its first year of operation in 2006 with the acceptance high school graduates, is a two-step, eight-year program equally divided between four years in an undergraduate college and four years in medical school with enhanced academic and financial support for the students. In the BA/MD program, students earn a bachelor of arts or sciences degree, a medical degree, and a certificate in public health. It features a challenging liberal arts curriculum that introduces the principles of public health and offers unique rural medical preceptorship opportunities that begin in the undergraduate years and continue throughout medical school. Students work with a community physician mentor in summer service-learning projects during the undergraduate years, then they return for required rural medicine rotations in the first, third, and fourth years of medical school. Simultaneously, the classroom curriculum for these rural medicine experiences emphasizes the public health perspective. Ultimately, the BA/MD program will strengthen the health care services available to New Mexicans, both because there will be an increased number of physicians who have a cultural identification with New Mexico's residents remaining in the state and because of the graduates' improved ability to apply the tools and skills of public health to community needs.
The admission process for the BA/MD program encourages applications from students in rural and medically underserved communities in New Mexico. The UNM faces challenges in identifying, recruiting, and retaining qualified rural students to its challenging programs because of recognized inadequacies in math and science education in many schools in the state. Conclusions from the National Center for Public Policy and Higher Education 2006 Report Card illustrate the difficulty:
New Mexico is among the lowest-performing states in math and reading. Hispanics in the 9th to 12th grades are about two-thirds as likely as whites to enroll in upper-level math courses, and one-half as likely as whites to enroll in upper-level science courses. Native Americans in the 9th to 12th grades are one-half as likely as whites to enroll in upper-level math and science courses.8
Working in partnership, UNM School of Medicine and College of Arts & Sciences BA/MD committee members and staff traveled to many rural and underrepresented minority communities to explain the program, recruit promising students, and begin a long-term process of promoting stronger math and science education at the local level. By enhancing the pipeline of students from traditionally underserved communities, the school is committed to graduating more homegrown physicians selected from the diverse populations in the state. The hope that these students will maintain the commitment they expressed at admission to provide health care to the medically underserved in New Mexico is warranted by the experience in the literature that students who express such interest at admission are more likely to practice in rural settings.3–5 Admission criteria for all students include a balance of both cognitive achievement (GPA and ACT scores) and noncognitive variables such as significant community involvement and leadership, which have been shown to be important predictors of minority success in medical school.6,9
The undergraduate component of the BA/MD program is known as Health, Medicine and Human Values. The program provides an enriched premedical liberal arts education in which all the students must meet the requirements for a bachelor's degree at UNM. The students have three options leading to the BA degree, all of which include a premedical sciences core of mathematics, chemistry, biology, physics, biochemistry, and a suite of courses in the humanities and social sciences to prepare the student for medical school. Special courses designed for the Health, Medicine, and Human Values component consist of the following five interdisciplinary seminars and a rural medicine preceptorship designed to illustrate the interconnections among the fine arts, humanities, social sciences, medicine, and public health.
▪ Contours of Health in New Mexico explores ethnic, economic, demographic, and geographic variables impacting public health in New Mexico and the Southwest.
▪ Literature, Fine Arts, and Medicine explores links among health, illness, literature, and the arts in a diverse range of forms and genres.
▪ Health Economics, Politics, and Policy explores political and economic forces that affect health care policies and practices.
▪ Health and Cultural Diversity explores cultural variables that affect the experience and practice of health and health care: how culture, ethnicity, race, and gender inform ideas of health and illness, death and dying, and the patient–physician relationship.
▪ Ethics, Medicine, and Health explores ethical and legal considerations that influence medical practices and decision making.
The rural medicine preceptorship occurs in the summer between the second and third years and allows students to engage in experiential learning projects in community and clinical health, mentored by community physicians. List 1 shows the sequence in which most students take the seminars and premedical sciences core.
The seminars and preceptorship promote personal growth by cohort building, small-group study, and experiential and problem-based learning (PBL). When students or residents are surveyed, they are more interested in PBL-type courses; such courses have been shown to increase both student performance and student satisfaction.10 These positive relationships in a PBL curriculum can reduce the attrition rate for at-risk, educationally disadvantaged students, allowing more of them to complete the curriculum.11
Because the focus of the UNM program is on the needs of underserved and minority communities and their populations, the development of specific competencies to address those needs are an explicit part of the program. These competencies are (1) the ability to acknowledge and integrate into medical care differences in race, gender, class, ethnicity, and culture when evaluating patients' personal issues, medical problems, and outcomes and evaluating health policies, and (2) to integrate a public health perspective into medical practice. The aim of training students in these competencies is to foster effective health delivery in rural and other medically underserved communities in New Mexico. These competencies will be reinforced during the medical school years, in which all students take an integrated PBL curriculum with a strong emphasis on the populations of New Mexico. All UNM medical students have a required eight-week rural medicine rotation that includes a community project in the summer after the first year and another four-week Medicine in New Mexico rotation in the fourth year. The required senior ambulatory medicine rotation consists of ethics and public health seminars and a senior project that integrates both public health and ethics. Work is in progress on a comprehensive curriculum revision to add a certificate in public health for all medical students beginning in 2010, when the first BA/MD cohort will enter the medical school, expanding the class to approximately 100 students.
Academic and Personal Support
The very low socioeconomic base of the state represented both the reason for the program and a major barrier to success; about 28% of New Mexico children under age 18 live in poverty, compared with a national rate of 18%. The National Center for Public Policy and Higher Education graded New Mexico as failing relative to other states for affordability of a four-year college education.
For these students at public four-year colleges and universities, net college costs represent 41% of their annual family income. These costs have increased since 1992. The state makes a very low investment in need-based financial aid compared with top-performing states, and New Mexico offers no low-tuition college opportunities.8
All who worked on the BA/MD program recognized the imperative to reduce the financial burden to the students to relieve the worry about how they will pay for tuition, books, or food. The goal of the program is to ensure that each BA/MD student receives a scholarship and grants package that meets the basic undergraduate educational costs of attending UNM and living on campus, currently around $14,000. Their financial support allows the students to focus on their studies, rather than working to pay their undergraduate expenses. Only through significant financial aid could these students hope to complete the program in eight years.
The Sophie Davis School of Biomedical Education at the City College of New York BS/MD program recognizes the importance of academic and personal support in the success of students with educational disparities.12 Adapting elements of this model, UNM has established comprehensive academic and student support services such as personal advising and counseling, tutoring, and supplemental instruction integral to the BA/MD program. Currently at UNM, the average undergraduate academic-advisor-to-student ratio is 1 to 400. Recognizing the critical importance of support for students from educationally disadvantaged backgrounds, this program includes a dedicated BA/MD advisor, tutoring, supplemental instruction, and mentoring by medical school faculty. The academic-advisor-to-student ratio in the BA/MD program is 1:60.
Living and Learning Community
Greenhalgh et al,13 in a study of academically gifted, socioeconomically diverse 14- to 16-year-olds who were considering medicine as a career, made the important observation that
underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded.
One attempt to address these complex issues is the Living and Learning Community program within UNM. Open to all high school freshmen, the Living and Learning Community students share common academic interests, live in the same residence hall, participate in a weekly seminar, and enroll in additional classes together. The BA/MD students form their own living and learning community. Current students in their first year of the BA/MD program strongly agreed in their endorsement of the undergraduate component of the program (mean rating, 4.9 on a 5-point Likert scale).
The BA/MD program is a resource-intensive one. Faculty and staff continue to devote extensive time to design the program, develop new courses, and participate in recruiting, admission, and mentoring. UNM hired new staff for admission and student support. The majority of new funds appropriated by state legislature were allocated to the college of arts and sciences to hire faculty, teaching assistants, and an academic advisor specialist (whose total effort is dedicated to ensuring the success of the students), and to fund the tutoring center to design specific assistance for the BA/MD students. The school of medicine received funding for faculty involved in program leadership, recruitment, course development, and mentoring as well as for staff support. Direct scholarship and financial aid packages for these students have been a significant part of the funding from the state legislature.
An intensive effort to engage key stakeholders throughout the state occurred during a three-year period in parallel with the process of program design. Rural community leaders in medicine, education, and business participated in discussions of the program in their own communities and contributed their ideas on key elements for success, such as financial aid. The New Mexico Medical Society leadership provided opportunities for the dean of the school of medicine to present the rationale and design of the program at a variety of member forums. Undergraduate departments that contribute to the education of premed students had opportunities early in the process to discuss the program with school of medicine representatives at their faculty meetings and joined actively in planning the program. The deans of the school of medicine and college of arts and sciences and the president of UNM gave the BA/MD program their top priority in requesting legislative funds. The New Mexico state legislature responded with special appropriations to cover the cost of the program.
Outcomes So Far and an Evaluation Plan
In its first year (2006), the program received 140 applications for 25 regular and 5 alternate positions. All of the students offered admission to the program enrolled, although one student did not meet the math requirements after a summer bridge program. Seventy percent of the students in the first class graduated from high schools outside greater Albuquerque; 60% are underrepresented minority students. A survey of students' views about the program indicates that they are satisfied to very satisfied with the academic courses, student support, and living–learning community aspects of the program.
In the second year, the program received 188 applications; 57% of the students who accepted the offer of admission are underrepresented minorities, and 65% are from rural communities.
Significant work involving multiple stakeholders resulted in a comprehensive plan to evaluate program outcomes. List 2 illustrates the areas of evaluation and types of outcomes in the plan.
The evaluation plan for the UNM program is indebted to the research of others involved in BA/MD and pipeline programs for many of its evaluation and outcome ideas. These other sources include the Sophie Davis model described by Roman and McGanney14 and by Roman,12 the University of Texas–Pan American and Baylor College of Medicine model developed by Thomson et al,15 and the evaluation of the University of California's postbaccalaureate programs for minority and disadvantaged students developed by Grumbach and Chen.16
UNM has committed itself to allocate 100% of its increased school of medicine enrollment to a program designed to expand opportunities in medical education to New Mexico students, especially those from rural and underserved minority communities, and to prepare them to practice in underserved areas of New Mexico. The program has received strong support from communities, the New Mexico state legislature, the New Mexico Medical Society, and the faculties of arts & sciences and the school of medicine. Early results demonstrate strong interest from applicants and enthusiasm of the students and faculty alike in working toward the goal of improving the health status of New Mexico.
1 Rosenblatt RA, Whitcomb ME, Culien TJ, et al. Which medical schools produce rural physicians? JAMA. 1992;268:1559–1565.
2 New Mexico Comprehensive Strategic Health Plan for 2006. New Mexico Health Policy Commission, Santa Fe, NM, 2006. Available at: (http://hpc.state.nm.us/reports
). Accessed March 1, 2007.
4 Pacheco M, Weiss D, Vaillant K, et al. The impact on rural New Mexico of a family medicine residency. Acad Med. 2005;80:739–744.
5 Rabinowitz HK, Diamond JJ, Markham FW, Rabinowitz C. Long-term retention of graduates from a program to increase the supply of rural family physicians. Acad Med. 2005;80:715–716.
6 Calkins EV, Willoughby TL, Arnold LM. Predictors of performance of minority students in the first two years of a BA/MD program. J Natl Med Assoc. 1982;74:625–632.
7 Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med. 2002;77:790–798.
9 Sedlacek WE, Prieto DO. Predicting minority students' success in medical school. Acad Med. 1990;65:183–187.
10 Casey PM, Magrane D, Lesnick TG. Improved performance and student satisfaction after implementation of a problem-based preclinical obstetrics and gynecology curriculum. Am J Obstet Gynecol. 2005;193:1874–1878.
11 Iputo JE, Kwizera E. PBL improves the academic performance of medical students in South Africa. Med Educ. 2005;39:388–393.
12 Roman SA Jr. Addressing the urban pipeline challenge for the physician workforce: the Sophie Davis model. Acad Med. 2004;79:1175–1183.
13 Greenhalgh T, Seyan K, Boynton P. “Not a university type”: focus group study of social class, ethnic, and sex differences in school pupils' perceptions about medical school. BMJ. 2004;328:1541–1546.
14 Roman SA, McGanney ML. The Sophie Davis School of Biomedical Education: the first 20 years of a unique BS/MD program. Acad Med. 1994;224–230.
15 Thomson WA, Ferry PG, King JE, Martinez-Weldig C, Michael LH. Increasing access to medical education for students from medically underserved communities: one program's success. Acad Med. 2003;78:454–459.
16 Grumbach K, Chen E. Effectiveness of University of California postbaccalaureate premedical programs in increasing medical school matriculation for minority and disadvantaged students. JAMA. 2006;296:1079–1085.
17 Marshall RE. Measuring the medical school learning environment. J Med Educ. 1978;53:98–104.
18 Crandall SJ, Volk RJ, Loemker V. Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians? JAMA. 1993;269:2519–2523.
19 Crandall SJ, Volk RJ, Cacy D. A longitudinal investigation of medical student attitudes toward the medically indigent. Teach Learn Med. 1997;9:254–260.
20 Blue AV, Basco WT, Geesey ME, Thiedke CC, Sheridan ME, Elam CL. How does pre-admission community service compare with community service during medical school? Teach Learn Med. 2005;17:316–321.
21 Blue AV, Geesey ME, Sheridan ME, Basco WT. Performance outcomes associated with medical school community service. Acad Med. 2006 81(10 suppl):S79–S82.