McDougle, Leon MD, MPH; Way, David P. MEd; Rucker, Yosman L. MSc
Premedical postbaccalaureate programs (PBPs) are designed to enhance the academic readiness of students with undergraduate degrees in order to improve their chances for successful admission into and completion of medical school. Multiple publications describe short-term and intermediate outcomes such as, respectively, rate of acceptance into medical school and medical school performance of PBP participants.1–9 However, we could find no control group studies reporting the long-term outcome of service provided by practicing physicians who were graduates from PBPs to patients who were medically indigent (e.g., on Medicaid or uninsured) and/or poor.1–9
The Institute of Medicine and the U.S. Department of Health and Human Services advocate improvement of the racial and ethnic diversity of the physician workforce to diminish health care disparities.10,11 Physician workforce diversity decreases health care disparities by improving health care access, patient satisfaction, and patient compliance with treatment plans through culturally competent communication.10–12
PBPs that focus on preparing underrepresented minority (URM) and disadvantaged students for successful completion of medical school enhance physician workforce diversity.5 Historically, URM physicians have reported a greater interest in establishing practices that provide care for underserved communities.13,14 The Association of American Medical Colleges Medical Student Graduation Questionnaire reports that 62.5% of Native Hawaiian/Other Pacific Islanders, 50.4% of blacks and African Americans, 40.9% of American Indians and Alaskan Natives, and 33.2% of Hispanics planned to practice in an underserved area. In contrast, 18.4% of non-Hispanic whites and 15.2% of Asians planned to practice medicine in an underserved area.14 However, few or no long-term follow-up studies have determined whether the populations these physicians subsequently served matched their interests at graduation from medical school.
Rabinowitz and colleagues15 identified four independent predictors of providing care to underserved populations: (1) being a member of an underserved ethnic/minority group, (2) participating in the National Health Services Corps, (3) having a strong interest in practicing in an underserved area before attending medical school, and (4) growing up in an underserved area. Eighty-six percent of generalist physicians with all four predictors were providing substantial care to underserved communities, compared with 65% with three predictors, 49% with two predictors, 34% with one predictor, and 22% with no predictors. Gender, family income while growing up, and curricular exposure to underserved populations during medical school were not independently related to caring for the underserved.15
This is a control group study of physicians who graduated from The Ohio State University College of Medicine (COM) between 1996 and 2002. The physicians of particular interest to this study participated in the college's MEDPATH PBP for 12 months before medical school matriculation. We investigated the actual practice location and characteristics of the patient population served by the PBP and control graduates as well as predictors of their caring substantially for the underserved.
The MEDPATH PBP
The MEDPATH PBP accepted its first cohort in 1991 and has since accepted 10 to 15 applicants annually, depending on funding. The MEDPATH program was designed to enhance the academic preparation of URM and disadvantaged students who were unsuccessful in their attempts to gain direct admission to any medical school. Students may learn about the MEDPATH PBP via the Web site (http://medicine.osu.edu/students/diversity/programs/medpath/pages/index.aspx), printed recruitment literature, and/or word of mouth. Admissions personnel review the applicants of candidates who were not admitted into The Ohio State University COM. They invite 30 candidates to interview on-site for the PBP. These candidates are all applicants who did not gain admission to any medical school, who are from disadvantaged backgrounds and/or of URM status, and who, with a bit more training, could potentially be very successful. The interviews are similar in format to the interviews for direct admission to the COM (i.e., they include interview by a faculty member and an admissions committee vote). Of the 30 invited, admissions personnel and faculty select 10 to 15 participants on the basis of their MEDPATH application, medical school application, and interview.
Once accepted into the MEDPATH PBP, program participants complete 12 months of prescribed course work, customized for the individual students to compensate for deficiencies in their academic preparation. Each student's development plan includes a review of learning strategies and test-taking skills and of basic sciences and biomedical sciences, such as intermediate biochemistry, microbiology, and physiology. The summer quarter immediately preceding matriculation to the first year of medical school includes courses in gross anatomy, neuroanatomy, genetics, and immunology.
MEDPATH PBP students are required to maintain a grade point average of at least 3.0 in the postbaccalaureate courses to matriculate into medical school. They must also retake the Medical College Admissions Test and attain a composite score that demonstrates academic progress (i.e., a minimum score of 24). The current MEDPATH PBP student selection and retention criteria are described in detail in another publication.2
Nearly all MEDPATH PBP students receive scholarship support from The Ohio State University and COM that covers full tuition for the 12-month program. Likewise, nearly all of the students receive medical school faculty mentorship. Tutoring is also available at no cost to students.
We identified 49 MEDPATH PBP physicians who graduated between 1996 and 2002, but two proved to be untraceable. We selected a stratified, random control group sample from the population of physicians from the same graduating classes. We assigned random numbers to members of each graduating class using the SPSS version 17.0 (Chicago, Illinois, 2008) random number generator. Using this number, we conducted a sort for each class, and we drew the first N graduates (where N is the corresponding number of MEDPATH PBP graduates from that class). We drew 59 control group physicians; however, one proved to be untraceable. Two physicians had not yet completed training, and we subsequently excluded their answers from the respondent data.
We assembled a questionnaire, modeled after a study by Rabinowitz and colleagues15 that evaluates predictors of generalist physician care for underserved populations, in order to facilitate comparison of our new findings with those of Rabinowitz and colleagues15 as well as with other future studies addressing predictors of care for the underserved. Our questionnaire comprised basic demographic questions along with questions about the physician's specialty, patient population, and intended patient population. We obtained contact information for the study participants through medical center records and a background check service. We found valid mailing addresses for all but three of the target sample, and we mailed our questionnaires via the U.S. Postal Service. Nonresponders received a postcard reminder one week later. We mailed another letter and questionnaire to nonresponders three weeks after the initial mailing, and finally, we sent a certified letter and survey to all nonresponders about six weeks after the initial mailing. We provided no incentives for completing the surveys. This study received institutional review board exemption from The Ohio State University COM.
We calculated descriptive statistics and a summary score, based on the Rabinowitz predictors,15 for each respondent. We compared the MEDPATH PBP group with the control group to determine whether selection or participation in the MEDPATH PBP contributed to providing substantial care to underserved communities. We performed chi-square tests (Fisher exact tests) to compare the MEDPATH PBP program group with the control group on the survey items, again using SPSS version 17.0 (Chicago, Illinois, 2008).
The overall response rate was 73/103 (70.9%). We received responses from 34 of the 47 (72.3%) physicians who were graduates of the MEDPATH PBP and from 39 of the 56 (69.6%) physicians in the control group. A validity check of the demographic information confirmed that all MEDPATH PBP respondents were either from a URM group or an economically disadvantaged background (Table 1).
Compared with the control group, the MEDPATH PBP graduates were more likely to be working in primary care practices such as internal medicine, family practice, pediatrics, or internal medicine/pediatrics (70.6% versus 35.9%, P < .005). As a whole, whether they were primary care physicians or not, the MEDPATH PBP graduates were also significantly more likely to be providing care to the underserved by either practicing medicine in a federally designated underserved area16 (29.4% versus 5.1%, P < .009) or providing service to a practice population that consisted of patients who were medically indigent or poor (67.6% versus 33.3%, P < .005). MEDPATH PBP graduates were also more likely to be volunteering their services (47.1% versus 10.3%, P < .001; Table 2).
Our results, like those of Rabinowitz and coinvestigators,15 showed that clinical experience with the underserved during medical school was not predictive of physicians practicing in underserved areas or providing substantial care for the poor (Table 2). However, the summary Rabinowitz predictor scores of care for the underserved, calculated by counting the number of Rabinowitz predictors present for each respondent, were significantly higher for the MEDPATH PBP physicians (t = 8.11, df = 71, P < .001; mean [standard deviation]: MEDPATH PBP = 2.35 of 4 [0.848]; control = 0.69 of 4 [0.893]; Tables 3 and 4).
We compared specialty board certification rates of the MEDPATH PBP and control group physicians to determine MEDPATH's potential impact; however, there was only a minor difference in specialty board certification rates: 81.8% and 84.6%, respectively.
The results from this control group survey are consistent with prior studies that have shown an increased likelihood of physicians from disadvantaged backgrounds and/or of URM status providing care for patients from underserved communities.12,14,15 Nearly 68% of practicing physicians who were graduates of the MEDPATH PBP were providing substantial care to underserved communities in their current practices as compared with 33.3% of the physicians from a comparable control group. In addition, nearly twice as many of the MEDPATH PBP graduates (70.6%) were currently volunteering, or planning to volunteer, services to underserved communities outside their practice as compared with their counterparts in the control group (35.9%).
Limitations of this study include a relatively small sample size, self-reported data, and data collected from practicing physician graduates of only one midwestern medical school and its affiliated MEDPATH PBP. Because this particular midwestern PBP focused on URM and disadvantaged students, it is difficult to separate the effects of the MEDPATH PBP from Rabinowitz and colleagues'15 independent predictors regarding the provision of substantial care for the underserved. There may be other factors that help explain the higher rate of care for the underserved that were not investigated. For example, perhaps the interview process helps select students who have demonstrated a stronger interest in community service. In addition, the mentoring provided by the mostly URM faculty mentors may have influenced the MEDPATH PBP participants' decisions with regard to service.
This is likely the first control group study demonstrating the increased likelihood of graduates of a PBP providing health care to patients who are medically indigent (e.g., on Medicaid or uninsured) and/or poor. Both primary care and non-primary-care specialists who completed the PBP provided health care to more patients who were medically indigent than did their non-PBP classmates. Larger, multiinstitutional control group studies are needed to further evaluate the long-term outcomes of PBPs that are designed to enhance workforce diversity.
The authors would like to thank Elise Kauffman, Seth Kantor, MD, Rebecca Mehling, Leibert Morris, Sara Rodriguez, MD, Martha Sucheston, PhD, Manuel Tzagournis, MD, Wilburn Weddington, MD, and Chris Yash, MA.
This study received institutional review board exemption from The Ohio State University College of Medicine.
The authors presented an earlier version of this article at the Medical Education for the 21st Century: Teaching for Health Equity Conference; December 3, 2008; Havana, Cuba.
1U.S. Department of Health and Human Services. Office of Minority Health and Health Resources and Services Administration, Bureau of Health Professions. An Annotated Bibliography: Evaluations of Pipeline Development Programs Designed to Increase Diversity in the Health Professions. Available at: http://bhpr.hrsa.gov/healthworkforce/pipelinebibliography.htm
. Accessed September 21, 2009.
2McDougle L, Way DP, Yash C. Effectiveness of a premedical postbaccalaureate program in improving medical college admission test scores of underrepresented minority and disadvantaged students. J Natl Med Assoc. 2008;100:1021–1024.
3McGlinn S, Jackson EW, Bardo HR. Postbaccalaureate medical/dental education preparatory program (MEDPREP) at Southern Illinois University School of Medicine. Acad Med. 1999;74:380–382.
4Jackson EW, McGlinn S, Rainey M, Bardo HR. MEDPREP—30 years of making a difference. Acad Med. 2003;78:448–453.
5Grumbach K, Chen E. Effectiveness of University of California postbaccalaureate premedical program in increasing medical school matriculation for minority and disadvantaged students. JAMA. 2006;296:1079-1085. Available at: http://jama.ama-assn.org/cgi/reprint/296/9/1079
. Accessed September 21, 2009.
6Strayhorn G. A pre-admission program for underrepresented minority and disadvantaged students: Application, acceptance, graduation rates and timeliness of graduating from medical school. Acad Med. 2000;75:355–361.
7Cantor JC, Bergeisen L, Baker LC. Effect of intensive educational program for minority college students and recent graduates on the probability of acceptance to medical school. JAMA. 1998;280:772–776.
8Giordani B, Edwards AS, Segal SS, Gillum LH, Lindsay A, Johnson N. Effectiveness of a formal post-baccalaureate pre-medicine program for underrepresented minority students. Acad Med. 2001;76:844–848.
9Blakely AW, Broussard LG. Blueprint for establishing an effective postbaccalaureate medical school pre-entry program for educationally disadvantaged students. Acad Med. 2003;78:437–447.
10Smedley BD, Stith AY, Nelson AR, eds; Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press; 2002. Available at: www.nap.edu/catalog/10260.html
. Accessed September 21, 2009.
11National Center for Health Workforce Information and Analysis, Health Resources and Services Administration Bureau of Health Professions. The Key Ingredient of the National Prevention Agenda: Workforce Development. A Companion Document to Healthy People 2010. Available at: ftp://ftp.hrsa.gov/bhpr/nationalcenter/hp2010.pdf
. Accessed September 21, 2009.
12Komaromy M, Grumbach K, Drake M, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305-1310. Available at: http://content.nejm.org/cgi/reprint/334/20/1305.pdf
. Accessed September 21, 2009.
15Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. The impact of multiple predictors on generalist physicians' care of underserved populations. Am J Public Health. 2000;90:1225-1228. Available at: http://www.ajph.org/cgi/reprint/90/8/1225.pdf
. Accessed September 21, 2009.
16U.S. Department of Health and Human Services, Health Resources and Services Administration. Shortage Designation: HPSAs, MUAs & MUPs. Available at: http://bhpr.hrsa.gov/shortage
. Accessed September 30, 2009.