Just as there are orphan diseases and orphan medications—conditions and their treatments that do not command the attention of drug developers and manufacturers—there are orphan programs in health workforce development. Postbaccalaureate premedical programs in the United States that support the health career aspirations of individuals from disadvantaged and underrepresented backgrounds fall into this category of orphans. These programs, however, address a compelling problem—inadequate diversity among the nation's medical students and physicians. Nearly two-thirds of medical students come from families in the top quintile of household income. African Americans, Latinos, and American Indians represent only 9% of the nation's physicians while constituting 25% of the nation's population.1 Research indicates that postbaccalaureate premedical programs are highly efficacious in increasing the likelihood that applicants from groups underrepresented in medicine will compete successfully for admission to medical school.2 Yet these programs typically find little stable support or educational institutional “ownership,” falling as they do in the no-man's land between baccalaureate degree-awarding colleges and medical schools.
The article in this issue of Academic Medicine by Andriole and Jeffe3 adds important new information to the conversation about postbaccalaureate premedical programs. First, the authors provide information that helps to distinguish between the two main types of postbaccalaureate programs. Postbaccalaureate programs of the first type focus on college graduates from underrepresented backgrounds, often those who have unsuccessfully applied previously for admission to medical school, and provide intensive academic and social support, MCAT preparation, coaching in the application process, and upper-level science course work to enhance the ability of these individuals to gain admission to medical school. Fees for students enrolling in these programs are usually steeply discounted, with programs relying heavily on nonstudent sources of operating funds. These programs are often administered by medical schools, with about 20 such programs currently in operation. Some have formal arrangements with their sponsoring medical school about conditional admission of students who achieve certain standards in their postbaccalaureate course of study. A very different breed of postbaccalaureate program is the “career changer” program. These programs are geared toward college graduates who did not pursue a premedical pathway in college, offering them an opportunity to complete premedical course requirements after college graduation. Educational institutions other than medical schools often administer these programs and typically charge students full tuition. The article by Andriole and Jeffe suggests that about equal numbers of medical students participate in each type of postbaccalaureate program, with 15% of medical students overall having completed a postbaccalaureate program. As expected, students who participated in the academic record enhancer programs were more likely to be underrepresented minorities and less likely to have a physician parent than those who participated in the career changer programs.3
The study by Andriole and Jeffe also adds to the evidence of the efficacy of academic record enhancer postbaccalaureate programs. A previous, controlled cohort study of postbaccalaureate programs administered by the five University of California medical schools concluded that these programs were highly effective in helping underrepresented and disadvantaged students succeed in matriculating into medical school, with the odds of medical school matriculation being 6.3 times higher for program participants than for nonparticipants in analyses adjusting for college grade point average and other student characteristics.2 Less has been known about what happens to postbaccalaureate students after they matriculate into medical school. The study by Andriole and Jeffe3 indicates that 95% of medical school matriculants who had completed an academic enhancer postbaccalaureate ultimately graduated from medical school, almost the same graduation rate as found among matriculants who did not complete a postbaccalaureate program (97%). The study also found that participation in a postbaccalaureate program was a significant predictor of medical students' intent at graduation to practice in an underserved area. The strongest predictor of this intent was entering the specialty of family medicine; of relevance, our own ongoing research on University of California postbaccalaureate participants who matriculated into medical school found that these individuals were more likely to select careers in family medicine than were their counterparts (unpublished data). A recent longitudinal study of Ohio State University academic record enhancer postbaccalaureate program completers who graduated from medical school concluded that these individuals were more likely than were medical graduates who did not participate in a postbaccalaureate program to practice in a federally designated Health Professions Shortage Area after completion of residency training.4
Postbaccalaureate programs targeting minority and disadvantaged students not only seem to be a very effective intervention for increasing physician diversity and producing a workforce more disposed to addressing the needs of the underserved—they also look to be a very cost-effective intervention. A program cost in the range of $20,000 per student yields a high likelihood that a student who otherwise probably would not have matriculated into medical school will enter the physician workforce. Considered in the context of the cost of educating a medical student, which is approximately $400,000 for four years of medical school,5 a one-time cost of $20,000 for a postbaccalaureate course of study seems a very reasonable investment to promote medical student diversity.
Academic enhancer postbaccalaureate programs targeting minority and disadvantaged students are part of a constellation of programs commonly referred to as health career educational pipeline programs.6 Many observers, noting the tremendous inequities in primary K-12 education and the great “leakage” of human potential at these early stages of the educational pipeline, have concluded that emphasis should be placed on interventions at these upstream stages to ultimately create a larger pool of competitive medical school applicants from disadvantaged backgrounds. However, the types of whole-school reforms needed to transform public K-12 education, while absolutely necessary, require a political will and broad social commitment that is not fully evident. Moreover, for funders and advocates with the specific goal of enhancing the diversity of the health professions, it may be difficult to linearly connect the dots between a tailored investment in early education—a classroom science education enhancement for fourth graders or a health career mentoring program for seventh graders—and the number of students meaningfully touched by these interventions who, many years later, may eventually matriculate into medical school. One fact that is often not fully appreciated in discussions of pipeline programs is that, despite profound inequities in K-12 educational opportunity, a steadily increasing number of students from underrepresented backgrounds are obtaining baccalaureate degrees in the United States.1 Yet the increased numbers of underrepresented college graduates have not been matched in the past decade by a commensurate increase in the number of underrepresented students matriculating into medical school.
A strong case can be made that focused efforts to enhance medical student diversity should use a “distal to proximal” prioritization strategy. That is, the highest yield is likely to come from targeting individuals who have already come the farthest in their educational achievement and require a boost to get over the final hurdle to become more competitive applicants to medical school. Such a strategy would logically begin with academic record enhancer postbaccalaureate programs. A comprehensive strategy could then work backward to the pool of underrepresented and disadvantaged students attending college who would benefit from programs to improve their performance in premedical “weeder” courses, such as organic chemistry. Many underrepresented college students pursue premedical course work in college, but even those who entered college with relatively strong academic records in high school frequently struggle to attain competitive grades in premedical courses.7 Research has demonstrated that structured programs at the college level can enhance the performance of underrepresented students in science and math courses. Moving further proximally along the pipeline, interventions might include programs such as health career high school magnet programs. Ideally, pipeline programs within a region would coordinate with one another to form a relatively seamless progression of interventions along the educational pipeline.
Unfortunately, postbaccalaureate programs often are orphans in the world of medical education. Although many medical schools administer postbaccalaureate programs, they often do so with some ambivalence about whether these premedical programs are truly part of the school's mission as a professional-degree-awarding institution. As one director of a University of California postbaccalaureate program commented during a focus group we recently conducted among directors and staff, “We're here, but we're not really supposed to be here.” A few medical schools, most notably Wayne State University School of Medicine and Ohio State University College of Medicine, have demonstrated a sustained funding commitment to their postbaccalaureate programs. But the majority of career enhancer postbaccalaureate programs operate on a hand-to-mouth fiscal model, perennially struggling to piece together various bits of funding from their sponsoring medical school, student fees, and grants.
The federal government has also given mixed signals about funding for postbaccalaureate and other pipeline programs. One of the most important sources of federal grants for health career pipeline programs has been the Health Careers Opportunity Program (HCOP) administered by the Health Resources and Services Administration. Annual appropriations for HCOP were cut drastically several years ago, from $35.6 million in fiscal year 2005 to $4.0 million in each of fiscal years 2006 and 2007. The Affordable Care Act reauthorized HCOP at a funding level of $60 million in fiscal year 2010 and “such sums as necessary” through 2015. However, Congress appropriated only about a third of the authorized spending level, $22.1 million, in fiscal year 2010, and the president's budget request and Senate Finance Committee action for fiscal year 2011 were at this same $22.1 million level. (Authorization simply establishes the ceiling for program funding, with the actual fiscal year budget being specified through the congressional appropriations process.) Although spending on HCOP and related programs amount to the equivalent of minor rounding error for the nearly $450 billion federal discretionary budget, these programs remain extremely vulnerable in a political climate of heightened concern about deficit spending.
Academic enhancer postbaccalaureate programs have demonstrated their value. Medical schools and their partners now need to take the 2008 revised Liaison Committee on Medical Education (LCME) MS-8 standard on diversity and enrichment programs to heart and fully adopt postbaccalaureate programs as part of the medical education family. It would be logical for the Association of American Medical Colleges (AAMC) to spearhead this effort by formally creating a standing committee on postbaccalaureate programs within its Group on Diversity and Inclusion. Creating such a committee could send a statement to AAMC member schools that postbaccalaureate programs targeting underrepresented and disadvantaged students are integral to the medical school mission and schools' ability to meet LCME standards, and could provide an organizational nidus for a national consortium of academic record enhancer postbaccalaureate programs. In February 2010, the University of California, Davis School of Medicine hosted a meeting of postbaccalaureate program representatives from across the country in an effort to kick off a National Postbaccalaureate Collaborative. Support from a group such as the AAMC will be essential for this collaborative to succeed as more than a one-time event. Private foundations might well find that helping to support a National Postbaccalaureate Collaborative would be an efficient way of providing resources to strengthen the collective impact of postbaccalaureate programs nationwide.
Creating a more robust National Postbaccalaureate Collaborative must be matched by a commitment by individual medical schools to take more ownership of existing postbaccalaureate programs and create new programs where there is unmet need. One aspect of such a commitment is adequate financial support for postbaccalaureate programs. Other measures include actions such as educating and orienting medical school admissions committee members about postbaccalaureate programs and developing closer working relationships between a school's admissions committee and its postbaccalaureate program.
The federal government should fund programs such as HCOP at their fully authorized level. Congress should also direct the new National Health Workforce Commission created by the Affordable Care Act to develop a comprehensive national strategy for health career pipeline programs and use this framework to guide federal policies and programs. This framework might consider issues such as the relative merits of investment in distal and proximal educational pipeline interventions, with the aim of producing a more coordinated and strategically directed federal effort in this area. State governments also have a role to play in supporting postbaccalaureate programs as part of federal-state partnerships in workforce development.
Academic record enhancer postbaccalaureate premedical programs, for many years the orphans in the family of medical school education, deserve to be adopted once and for all as essential components of a comprehensive workforce development strategy to meet LCME accreditation standards and respond to the public's need for a diverse physician workforce.
The author appreciates the many helpful insights into postbaccalaureate programs provided by Jim Forkin, MA, MS, of the California Postbaccalaureate Consortium, and acknowledges the efforts of the members of the University of California, San Francisco postbaccalaureate evaluation team in advancing research on many of the issues discussed in this commentary.
The California Endowment has provided grant funding to Dr. Grumbach for evaluation of University of California postbaccalaureate premedical programs. The California Endowment had no involvement in the design and conduct of this commentary; collection, management, analysis, and interpretation of the content; or preparation, review, or approval of the manuscript.
1Grumbach K, Mendoza R. Disparities in human resources: Addressing the lack of diversity in the health professions. Health Aff (Millwood). 2008;27:413–422.
2Grumbach 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.
3Andriole DA, Jeffe DB. Characteristics of medical school matriculants who participated in postbaccalaureate premedical programs. Acad Med. 2011;86:201–210.
5Cooke M, Irby DM, O'Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, Calif: Jossey-Bass; 2010.
6U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions and Office of Public Health and Science, Office of Minority Health. Pipeline Programs to Improve Racial and Ethnic Diversity in the Health Professions: An Inventory of Federal Programs, Assessment of Evaluation Approaches, and Critical Review of the Research Literature. http://bhpr.hrsa.gov/healthworkforce/reports/RecruitReport.pdf
. Accessed October 20, 2010.