This study examines the long-term effectiveness of an institutional postbaccalaureate program designed to provide an opportunity for students from disadvantaged backgrounds to enter medical school and ultimately become physicians. The study follows student cohorts for an 18-year period by assessing achievement of specific academic milestones. There are continuing conversations on the national level regarding the importance of diversity in the profession of medicine.1 Many recent reports tie diversity issues to health care outcomes.2 The Association of American Medical Colleges (AAMC) launched Project 3000 by 2000 in 1991 to generate a national initiative aimed to increase diversity in medicine.3
Since 2000, the impending physician shortage in the United States has been a looming concern for the medical profession. By 2025, the AAMC estimates a shortage of 124,000 physicians nationwide.4 The composition of the physician workforce in future years must also be given attention. The 1997 AAMC publication, “Finishing the Bridge to Diversity,” states that medical education is obligated to cultivate tomorrow’s physicians. “[O]ur mandate is to select and prepare students for the profession who . . . bear a reasonable resemblance . . . of the people they will serve. In other words, a medical profession that looks like America.”1 There is a unique opportunity available in medical education with the intersection of the need to educate a larger number of physicians and the need to further diversify those who are trained as physicians for institutions to identify strategies that will collectively address both types of need to enroll a more diverse student body.
Postbaccalaureate programs provide strategic approaches to addressing the development and support of disadvantaged students. In 2003, Blakely and Broussard5 reported, “It is possible to construct a structured postbaccalaureate medical school program that addresses several pressing concerns.” The success rate of over 80% placement from the University of California (UC) Davis School of Medicine postbaccalaureate program of educationally disadvantaged students into medical school was reported in the same article. The UC Davis program is a reapplicant program focused on any student likely to return and practice in a medically underserved area. The students who complete the UC Davis program go on to attend various medical schools around the country. In contrast, the program addressed in the present study, Michigan State University College of Human Medicine (MSUCHM), offers conditional admittance to postbaccalaureate participants who successfully complete the program requirements.
The MSUCHM has historically been committed to the enrollment of students from diverse backgrounds. In the mid-1980s, MSUCHM designed a postbaccalaureate program that would allow the medical school to gradually increase the number of students from underrepresented minority and disadvantaged backgrounds in its entering class. The Advanced Baccalaureate Learning Experience (ABLE) Program began in 1986 with a class of four students.6 The pilot program was expanded in 1991 to allow approximately 10 disadvantaged students a year to participate. This study examines the outcomes for student participants in the ABLE Program from 1991 to 2008 with a focus on the students who matriculated into MSUCHM.
This report discusses outcomes associated with the ABLE Program at MSUCHM in response to the following questions:
1. What long-term success has the ABLE Program had in facilitating the entry of disadvantaged students into medical school?
2. As a programmatic quality indicator, what successes have ABLE Program participants had during the rigorous medical program after matriculation into MSUCHM?
3. To what degree has the ABLE Program provided a successful pathway for students from disadvantaged backgrounds to enter the medical profession, as evidenced by the graduation of ABLE alumni from MSUCHM?
4. What fields of medicine do ABLE Program alumni select at the time of their initial residency placement as they graduate from medical school?
This project is a retrospective analysis of ABLE Program participants since 1991. A database was developed from existing academic records for the program participants. The database included demographic and academic performance information from the AMCAS application, medical school performance, medical school academic progress, United States Medical Licensing Examination (USMLE) Step 1 performance, and residency match information. Program participants were subdivided into four groups: current medical students, medical school graduates, those who did not graduate from medical school, and those who did not matriculate into medical school. Comparisons among groups were conducted using chi-square tests for nominal variables and t tests or ANOVA for continuous variables. This project was reviewed by the MSU IRB.
The ABLE Program cohort for the years reviewed in this study (1991–2008) included 178 postbaccalaureate participants. Their demographics were as follows: 65% female, 35% male; 63% African American, 28% Hispanic, and 4% white. Fifty-eight percent (58%) were Michigan residents, and the average age of participants was 26.5 years. The pathway to the ABLE Program is through the submission of an AMCAS application to MSUCHM and recommendation by the MSUCHM Committee on Admissions. At the time of entry into the ABLE Program, the cohort’s AMCAS mean GPA scores were as follows: science GPA, 2.68; nonscience GPA, 3.16; and total GPA, 2.88. At completion of the ABLE Program, the mean science GPA for the cohort increased to 3.54, which was significant (t = 24.4, P < .001).
Examination of the data shows 94% (167/178) of the ABLE Program participants successfully completed the postbaccalaureate program, met the standards set by the Committee on Admissions, and ultimately matriculated as first-year students at MSUCHM. An additional 2.8% (n = 5) of the ABLE Program cohort successfully completed the program and met admissions criteria but chose to matriculate at a different medical school; 3% (n = 6) of the ABLE Program participants did not successfully complete the program.
Of the 167 ABLE Program participants who matriculated into MSUCHM during the period of this study, 64% (107) have graduated, 26% (44) are still enrolled in medical school, 3% (5) transferred to another medical school, and 7% (11) were either dismissed or withdrew because of poor performance during medical school. The retention rate for students outside of MSUCHM is slightly higher, at 94%. An analysis of the 107 ABLE participants who graduated from MSUCHM indicates the following: 63% graduated in four years, 18% in five years, and 19% in six or more years. All students at MSUCHM are allowed to extend their curricular program with the guidance and approval of administration and have up to eight years to complete the MD degree.
Table 1 compares the academic performance in select first-year basic science medical courses and the problem-based learning (PBL) second-year medical courses for ABLE Program alumni who matriculated into and graduated from MSUCHM with the performance of those who matriculated but were not successful in earning the MD degree. The first-year basic science courses selected represent courses that all students in the cohort completed regardless of their year of entry to the medical school. Because of curricular changes in the period covered by the study, all courses could not be used, since the medical school curricula for different cohorts were slightly different. In the anatomy and pathology courses, ABLE Program participants who graduated from MSUCHM earned mean scores that were statistically higher than ABLE Program participants who did not graduate from MSUCHM. However, all of the ABLE Program participants performed at levels consistent with mastery of the material in the courses. There was no statistical difference in the performance in pharmacology. There was also a statistically significant difference in the performance on the second-year PBL exam. On the first take of the USMLE Step 1 exam, ABLE Program students who were successful had a pass rate that was higher than those who were unsuccessful (69% versus 25%).
Table 2 presents the residency match data for the 107 ABLE Program participants who graduated from MSUCHM. Approximately 50% selected a primary care specialty field at the time of graduation, 23.4% chose a surgical specialty, 6.5% selected a support specialty, and 3.7% chose a medical specialty. Approximately 12% did not participate in the residency match during their senior year.
The ABLE program is an institutionalized approach used by MSUCHM to increase the enrollment of identified disadvantaged students. The students are identified and recommended annually by the MSUCHM Committee on Admissions during the regular admissions process. The program allows the college to strategically invest its resources in efforts to prepare a select group of students for success in medical school. The program focuses on the students developing educational skills to enhance their success within a rigorous medical school curriculum.
The ABLE Program provides conditional admissions to the students who successfully meet the performance guidelines established by the MSUCHM. The ABLE Program is very similar to the postbaccalaureate program at Wayne State University School of Medicine, which is designed to improve students’ scientific knowledge and academic skills in preparation for matriculation into medical school.7 Both programs require students to complete several basic science undergraduate courses and have a comprehensive academic skill component that focuses on increasing the students’ capacity to manage time effectively, study productively, use analytical strategies, and develop effective techniques for note taking, test taking, and reading comprehension. The postbaccalaureate program at the University of Michigan School of Medicine also enrolls students from a variety of backgrounds, including individuals who have been unsuccessful in gaining entry to medical school, and nontraditional students, such as those who were considering career changes.8 In 1972, Southern Illinois University School of Medicine (SIUSOM) began its Medical/Dental Education Preparatory Program.9 Unlike the programs at Wayne State and the University of Michigan, SIUSOM’s program was not a conditional admittance program. Despite the differences in structure and goals, the diversity of the physician workforce has undoubtedly increased because of the implementation of postbaccalaureate programs.10
This study is limited by reporting on only one site and the lack of postresidency follow-up of the graduates. Nevertheless, the study demonstrates that the MSUCHM postbaccalaureate program has been successful in matriculating program participants into MSUCHM. The results of this study support the decision of MSUCHM to make an investment in a promising group of students from disadvantaged backgrounds. This investment was worthwhile as indicated by the yield from the ABLE Program participants who have graduated.
The study findings indicate that the students improved their science GPAs during their participation in the postbaccalaureate program. The authors suggest this is due in part to the structure of the program, which uses a holistic approach to working with students and incorporates many proactive educational development activities. To use an analogy, the program “polishes” those diamonds in the rough, improving their academic preparedness for the medical school curriculum. A noteworthy improvement in the sciences contributes to the future success of the ABLE Program alumni while they are in medical school. There is a 90% success rate for those who enter MSUCHM from the ABLE Program. This is almost as high as the 94% retention rate for those who enter MSUCHM from outside of the ABLE program. The percentage entering primary care residencies is encouraging (50.5%) and is almost equal to the typical percentage from MSUCHM (51%), although admittedly we do not know how many go onto subspecialize. Perhaps a multiinstitutional study of career paths of postbaccalaureate graduates is warranted.
The diligence of medical education as a whole to address the challenges ahead in the physician workforce is recognized. This includes the recruitment, retention, and graduation of students from various backgrounds. The creation of similar postbaccalaureate initiatives by other medical schools could provide a strategy to increase diversity in the expanding classes of 21st-century medical schools.
For 18 years, the ABLE Program and other programs across the country have been addressing these challenges in some way. A follow-up to this study will be a more in-depth analysis of the practice patterns of the ABLE Program participants and the impact they are having in their practice communities.
The ABLE Program is supported in part by the Health Careers Opportunity Program, Division of Disadvantaged Assistance, HRSA, PHS, DHHS, Grant No. 5-D18-MB-01722.
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