Haq, Cynthia MD; Stearns, Marjorie MPH; Brill, John MD, MPH; Crouse, Byron MD; Foertsch, Julie PhD; Knox, Kjersti MD; Stearns, Jeffrey MD; Skochelak, Susan MD, MPH; Golden, Robert N. MD
Although the United States spends more money on health care than any other country—$8,362 per person in 20101—the population does not experience the best health outcomes and currently ranks 51st in life expectancy.2 Within the United States, many low-income populations experience significant disparities in health outcomes reflecting serious social inequalities.3
Access to primary health care is a key factor influencing the health of populations. Research has shown that health systems focused on primary care are associated with more effective, equitable, and efficient health services and that they achieve better population health outcomes at lower costs.4 Although health care reform may increase financial access to health care for millions of Americans, health services cannot be delivered without sufficient numbers of appropriately skilled health professionals distributed according to the needs of the population.5
More than 60 million, or nearly 20%, of Americans are living in primary care Health Professional Shortage Areas (HPSAs).6 HPSAs are inner-city or rural geographic areas, populations, or facilities designated by the U.S. Health Resources and Services Administration. HPSAs have fewer than one full-time primary care physician per 3,000 to 3,500 people—a number considered significantly short of the number needed to deliver essential primary health care services. Nearly half of all HPSAs are in urban metropolitan areas.6
In addition to the increasing shortage of primary care physicians, the nation is experiencing a shortage of physicians across most specialties. The Association of American Medical Colleges projects a shortage of more than 30,000 primary care and 33,000 non-primary-care physicians by 2015—and worsening shortages projected through 2025.5 Increasing the production of physicians will not resolve these specialty and geographic maldistributions as long as physicians perceive financial incentives in choosing select specialties and/or in practicing in communities that generate higher levels of reimbursement. Medical educators are seeking new models to attract, prepare, and retain physicians—both in primary care and subspecialties—to deliver high-quality health services for the entire nation, especially for HPSAs.7–9
A review of U.S. medical school programs designed to prepare students to care for medically underserved populations reveals a variety of formats and types of student engagement in rural and urban environments. Formats range from short electives or required courses10,11 to extended, multiyear commitments combining formal didactics, immersion in clinically underserved populations, and community health projects.12–25 These programs vary in their focus areas, curricular content, levels of student involvement, application/selection processes, and outcomes. Several have demonstrated increases in participating students’ empathy and knowledge,19,24 selection of primary care careers,15,17,19,23 and decisions to practice in HPSAs12,13,15,17,18,23 when compared with nonparticipants.
In 2005, in response to substantial health disparities in Wisconsin,26 the University of Wisconsin (UW) Medical School launched a bold curricular transformation with the vision of incorporating public health as an integral component of medical education. The school changed its name to the School of Medicine and Public Health (SMPH), reflecting the goal of bridging the schism that has separated the fields of medicine and public health for more than a century.27 As part of its transformation, the SMPH seeks to address health promotion and disease prevention at the level of populations, with an emphasis on populations that suffer substantial health disparities. The elimination of health disparities and the elevation of the health of all members of society are now foundational elements of the school’s missions of education, research, clinical practice, and service.28 By incorporating public health principles into the core medical curriculum, the SMPH intends to shape a new generation of health professionals who will naturally incorporate health promotion and disease prevention into their daily work.
More than 17% of the people of Wisconsin live in federally designated primary care rural or urban HPSAs29—a percentage similar to national shortages.6 The pressing need for increasing the physician workforce in underserved areas can be addressed, in part, through targeted programs that recruit, prepare, and retain clinicians who are committed to working with underserved populations. The SMPH has created new programs to respond to these needs. The Wisconsin Academy for Rural Medicine prepares rural physicians,30 and its sister program, Training in Urban Medicine and Public Health (TRIUMPH), prepares urban physicians.31 This report describes TRIUMPH and provides some early, short-term outcomes.
Program goals and oversight
TRIUMPH is designed to prepare medical students to become community-responsive physician leaders32 who are able to promote health equity for urban populations in Wisconsin and beyond. The program immerses students in clinical work within urban communities, exposes them to positive physician role models and community leaders, engages them in addressing complex community and public health problems, and encourages them to consider primary care or subspecialty medical careers serving urban underserved populations.
A faculty physician (C.H.) and public health professional (M.S.), both with extensive community health experience, lead the program, which started as a pilot program in 2009. An advisory committee—composed of SMPH faculty, Milwaukee physicians, community and public health leaders, and student representatives—meets regularly to review the program’s progress and guide its development.
Milwaukee Academic Campus
The SMPH has an established statewide network of urban and rural clinical training sites at which most students rotate during their third (M3) and fourth (M4) years of medical school. TRIUMPH students, however, complete the majority of their clerkships in Milwaukee, 90 miles from the main campus in Madison. Milwaukee is home to Aurora Health Care, a not-for-profit hospital and clinical network with a strong commitment to medical education,33 where up to 30% of UW medical students have participated in required clerkships for decades.
The City of Milwaukee contains the greatest concentration of Wisconsin residents living in a metropolitan HPSA (n = 317,721) and requires an estimated 22 additional primary care physicians to end its significant physician shortage.29 Of the city of Milwaukee’s nearly 600,000 inhabitants,34 41% have public health insurance and 16% have no health insurance.35 In Milwaukee, 38% of all families with children under 18, and 46% of all children, live in poverty. The infant mortality rate for African Americans born in Milwaukee in 2009 was 14.7/1,000 live births—the seventh worst among large cities in the nation, and more than twice as high as the rate for white infants.36
Student recruitment and selection
Students learn about TRIUMPH from the SMPH’s Web site, through classmates, and during brown bag information sessions held monthly during the fall semester. They apply and are selected during their second year of medical school. Students interested in any specialty may apply as long as they also have an interest in practicing in urban underserved areas. Applicants submit essays describing their background and their experience working with underserved populations or with people of lower economic status; they also submit letters of recommendation. The dean of students reviews applicants to confirm positive academic standing and professional conduct. A committee of faculty, community leaders, and two M4 TRIUMPH students selects applicants. Most applicants have participated in community service prior to and/or during the first two years of medical school. Selection criteria include demonstration of a strong service ethic and motivation to work in low-resource settings, because prior studies have confirmed that these factors predict a greater likelihood of future service to underserved populations.37
Students relocate from Madison to Milwaukee to begin TRIUMPH during their M3 year. Aurora Health Care provides housing; there are no additional financial incentives. Program capacity was initially 6 students per year (in the 2009 pilot) and has recently expanded to 16 per year—approximately 10% of the total class. A summer/fall program was added in 2011 to accommodate 8 additional students per year. Whereas most TRIUMPH students spend 10 to 15 months in Milwaukee over the course of their last two years of medical school, students in the summer/fall program spend only 6 months of their third year there. The program description and analysis of graduates in this article focus primarily on the 15-month TRIUMPH program.
Curriculum design and organization
The curriculum design reflects Fishbein and Ajzen’s38 theory of reasoned action, which proposes that attitudes and subjective norms are likely to shape future behavior and career decisions.39 The curriculum employs a conceptual framework that builds skills in three interrelated domains: (1) clinical, (2) community and public health, and (3) personal (List 1). TRIUMPH’s curriculum designers adapted the framework from the Montefiore Social Medicine residency program,40 revising the goals and activities to be appropriate for medical students and enhancing personal and peer support. Whereas TRIUMPH builds on the foundational work of Montefiore and others, it provides a unique blend of principles from asset-based community development,41 community-oriented primary care,42,43 servant leadership,44 evidence-based public health,45 culturally responsive health care,46 and mindful practice47 to cultivate compassionate care for self, for others, and for communities.48
The TRIUMPH curriculum is organized through courses that are concurrent with and add value to clinical clerkships so as to provide students with a deeper understanding of the history, context, and social determinants of health in Milwaukee and to enable them to immediately apply what they are learning in their courses to their clinical work and projects (Chart 1). Four sequential, interrelated courses are delivered as weekly seminars during the students’ third year, and every other week during their fourth year. Students attend “humanism rounds,” which are included in the seminars, throughout both years. Students also participate in two-week intensive courses, one in the third and one in the fourth year. Further, they are expected to devote at least 80 hours per year to their community projects.
Community and public health projects.
Students are excused from clinical duties to engage in service–learning projects one half-day per week throughout the duration of the program. Community leaders are invited to propose projects that align with Healthy People 2020 objectives,49 that address the needs of a target population, that enhance the capacity of the organization, and that engage and enhance students’ skills. The TRIUMPH faculty director (C.H.) then meets with students to present project options. After the students explore the options, they submit their preferences, and the director matches them with projects before they begin TRIUMPH. Students learn to define the population, gather and analyze data, conduct surveys, map assets, assess community needs, and work as members of interdisciplinary teams. They develop goals, objectives, logic models, work plans, and evaluation and sustainability strategies, all carefully tailored to fit the needs and circumstances of their projects’ target populations.
Seminars and humanism rounds.
Seminars afford students opportunities to share progress on their projects, solicit input from mentors and peers, practice mindful communication, and gain knowledge and skills. During these seminars, students share project-related celebrations, discoveries, intentions, and actions. Project seminars alternate with humanism rounds during which students share clinical and community narratives with personal reflections. Humanism rounds provide a supportive environment for students to discuss patient and community dilemmas or conflicts; progress and challenges; and reflections, responses, and feelings. Peers are instructed to listen carefully and to respond with compassion and in a nonjudgmental fashion rather than to focus on clinical issues. Each M4 student leads a seminar and selects readings on a topic of his or her choice. These seminars provide opportunities for senior students to teach, and they reinvigorate all the group members with new ideas.
TRIUMPH students complete the majority of their M4 rotations in Milwaukee while they continue the core curriculum seminars and projects. Students are allowed to spend up to four months of their senior year away from Milwaukee to complete rotations that are not offered in the city, to engage in rotations in residency training sites, or to pursue global health electives. All SMPH students are required to complete an M4 preceptorship, a six-week full-time rotation to enhance their clinical skills. TRIUMPH students, however, work specifically with inspiring urban physician role models in a longitudinal fashion over the entire year. Thus far, most M4 TRIUMPH students (24 out of 31) have been matched with preceptors in federally qualified community health centers.
The SMPH has invested significant institutional resources to ensure that the program provides benefits for students, communities, and institutional partners. The school receives partial funding from the State of Wisconsin for TRIUMPH and matches state support with additional school funds. Program costs are related to expanding relationships with existing clinical teaching sites, building partnerships with a network of community mentors and organizations that host student projects, delivering the core curriculum, and conducting evaluations. The program is supported by the following:
* a 0.40 full-time equivalent (FTE) physician faculty leader,
* a 0.33 FTE public health faculty leader,
* a 0.10 FTE faculty member with expertise in evaluation,
* a 0.25 FTE program assistant, and
* a 0.10 FTE administrative assistant.
Community organizations receive financial support for project mentors ($1,500 per student), and community members receive honoraria for organizing community events and presentations (a total of $4,000 per year). All of these expenses result in a total of net new costs of about $200,000 per year for 24 students (16 M3 + 8 M4 students), or about $8,300 per student. Start-up costs per student were greater not only because of the time and effort needed to design the program and to cultivate relationships but also because the program enrolled fewer students in the initial cohort.
One challenge in evaluating programs like TRIUMPH is that they purposely admit students who already have a strong interest in practicing in medically underserved areas, and this selection effect results in preexisting differences between program students and their peers that confound key outcomes. A second challenge is that the key outcome—in this case, the number of TRIUMPH graduates practicing in urban underserved areas, especially in Wisconsin—takes many years to emerge. A further complication is determining in which “cohort” to include the data (for analysis) of TRIUMPH students who delay completing medical school for some reason. A final challenge, especially in doing statistical analyses and making inferences regarding program effects, is that the program and its evaluation have changed over time (as should be the case for programs that use data to make improvements), so that what students experience in different years/versions of TRIUMPH gradually changes.
One key change—and a key distinction among TRIUMPH students of various cohorts—is that some have experienced a “full dose” of the program (six months of their M3 year and all nine months of their M4 year), whereas others have experienced only a partial dose (six months of their M3 year). In acknowledgment of these challenges, our formative evaluation was designed primarily to help improve the program over time and secondarily to assess longer-term outcomes. Proving that the program produces different outcomes than those seen in a control group of similarly oriented students was not a major goal of the evaluation because of the difficulties of finding such a comparison group and of controlling for changes in the program over time.
Program evaluation occurs annually and includes both quantitative and qualitative measures. Students complete surveys to provide detailed feedback after each course. Starting with the cohort that began in January 2010, they have also completed year-end surveys that allow program leaders to gauge students’ attitudes toward working with underserved populations as well as the overall effects and effectiveness of the program. Community leaders provide, via survey, their opinions about TRIUMPH students’ skills, plus information about their institution’s capacity to continue to accommodate students. TRIUMPH also collects students’ test scores and other academic information to evaluate participants’ progress, especially in comparison with other UW medical students. Finally, all TRIUMPH students participate in focus groups, which allows them to provide in-depth information about their experiences in the program. (See also Method.)
In addition to these various short-term evaluative measures, TRIUMPH has begun to conduct surveys to gather long-term outcomes data. These surveys ask graduate physicians to report on a variety of opinions and behaviors related to their roles in promoting and sustaining public health. (See also Method.)
The primary research question for this report—whether TRIUMPH students are more likely to remain interested in and be better prepared for careers in urban medicine because of their participation in the program than if they had not enrolled—can be answered only by looking at the data across all of our evaluation sources, the full set of which was not in place for the earlier cohorts (the cohort that began in January 2010 is the first cohort to complete the M4 portion of the program). Starting with the cohort beginning January 2010, we have evaluated the following sources of data:
1. Surveys of M3 and M4 students after each of their two-week intensive courses. Each survey, comprising 40 to 45 items, asks students to rate and comment on each session or activity, rate how well the course met each of its goals, and offer suggestions for improvement.
2. Year-end surveys of all TRIUMPH students that allow the program both to measure annual changes in students’ attitudes toward practicing in underserved areas and to determine the impact and effectiveness of all aspects of the TRIUMPH curriculum. Each survey, comprising 36 to 40 items, asks students to rate the effectiveness of and comment on all aspects of that year’s program. It also asks students to rate the program’s overall impact on their interest and confidence in working with underserved urban populations and on their knowledge, skills, and attitudes related to such work.
3. Year-end surveys of the community mentors that gather mentors’ ratings (on a five-point scale where 1 = Low and 5 = High) of students’ dedication to the project, curiosity/drive to learn, professionalism, and flexibility/ability to adapt to circumstances. Mentors also rate five aspects of the mentoring experience, provide information about their willingness to continue serving as mentors, and make suggestions on how to improve the program experience for mentors.
4. One-hour, tape-recorded, year-end, in-person focus groups with all the students in a cohort, facilitated by the TRIUMPH evaluator (J.F.), during which students discuss in-depth the effects of, the challenges they experienced during, and any suggestions they have for improving TRIUMPH.
5. Participating students’ course grades for all four years of medical school, Step 1 and 2 board exam scores, clerkship SHELF scores, and year-end professional skills assessment scores.
6. Postgraduation surveys of TRIUMPH and other UW medical students at one year (23 items), three years (27 items), and six years (27 items) post graduation that ask, among other things, the graduate’s specialty, whether he or she is currently and/or is ultimately planning to practice in Wisconsin and/or in medically underserved areas, and the degree to which she or he is engaged in various public health activities.
All surveys were conducted online by the program evaluator (J.F.), who quantified the multiple-choice responses and provided open-ended comments and analyses to administrators for program improvement. The same evaluator conducted the focus groups with all TRIUMPH M3 students and M4 students, tape-recorded and transcribed each session, and used thematic qualitative analysis to extract the main themes. The SMPH statistician used t tests and analysis of variance to conduct the statistical comparisons between TRIUMPH students and non-TRIUMPH SMPH students on standard medical knowledge and academic performance measures, using SPSS (Version 21; Armond, New York). TRIUMPH offered no incentives for completing surveys or for participating in focus groups; rather, TRIUMPH students are expected to participate in program evaluation as a condition of their enrollment. The UW institutional review board granted this evaluation exempt status.
Fifty-three students have enrolled in the TRIUMPH program between January 2009 and January 2013:
* 6 students enrolled in January 2009 for what was then only a 6-month version of the program;
* 4 sets of 8 students each (32 total across 2010, 2011, 2012, and 2013) enrolled in January of their M3 year for the full 15-month version of the program that includes 6 months of the M3 year and up to 9 months of the M4 year; and
* 2 sets of students (15 total: 8 in 2011; 7 in 2012) enrolled in a new 6-month version of the program that starts in July and ends in December of the M3 year.
Because many of the evaluation instruments were not in place until January of 2010, the 6 students from the 6-month pilot version of the program in 2009 are not included in our survey analyses. Further, although we are collecting data from the two sets of students who have enrolled in the 6-month summer/fall version of the program, the first set of those students will not graduate until 2013, so we are not reporting their survey data. Because these students’ experiences differ from those of 15-month TRIUMPH students (due to selection effects and a significantly shorter program that starts much earlier in their M3 year), we look forward to exploring whether there are also differences in the outcomes of those students and those who complete the 15-month TRIUMPH program. For the current analysis, we are focusing only on the 16 students (8 in each cohort) who began the full 15-month version of TRIUMPH in 2010 and 2011, for whom we have a complete set of evaluation data through to graduation.
For the two cohorts of 15-month TRIUMPH students who enrolled in January of 2010 and 2011, 93.8% (15/16) completed their M3 surveys and 81.3% (13/16) completed their M4 surveys. For these two cohorts, 84.2% (16/19) of their community mentors completed surveys.
The demographics of the 16 students in these two cohorts are as follows:
* 6 (38%) were male;
* the mean age was 27 (range 24–30);
* 5 (31%) were married;
* 3 (19%) self-identified as from a minority or low-income background;
* half were fluent in Spanish;
* 13 (81%) were Wisconsin residents; and
* all were from urban counties.
All 16 students had prior volunteer or paid experience working with underserved populations or with people of lower socioeconomic status.
TRIUMPH students have engaged in a wide range of community and public health projects through the program (Table 1). With few exceptions, community mentors have provided very positive feedback regarding their students’ dedication (mean rating on a 1–5 scale = 4.11, standard deviation [SD] = 1.27), curiosity/drive-to-learn (mean = 4.22, SD = 0.97), professionalism (mean = 4.22, SD = 0.83), and ability to adapt to changing circumstances (mean = 4.00, SD = 1.22). All mentors except one (whose program was undergoing significant changes) wished to continue hosting students in the future. Collectively, mentors have proposed more than twice as many projects as students available.
Outcomes for the students who enrolled in TRIUMPH in 2010
All eight of the students who enrolled in TRIUMPH in 2010 have graduated, although one graduated a year after her peers because of an extended third year teaching public health workers in the Dominican Republic.
Almost all of these students reported large to moderate increases in their knowledge and abilities in nine areas important to aspiring urban physicians in both their M3 and M4 years (Table 2). After the second year of TRIUMPH, the majority of this cohort experienced significant increases in their willingness to work with urban underserved populations (Table 3).
This cohort of TRIUMPH graduates performed as well as their peers in their Year 2, 3, and 4 classes, as determined by their grade point averages (GPAs). However, because of their lower-than-average Year 1 mean class GPA (UW stopped calculating Year 1 GPA when the next class switched to pass/fail), their overall GPA on graduation was 0.22 grade points lower than that of their non-TRIUMPH peers (significant at P = .02). These TRIUMPH students’ Step 1 and Step 2 board exam scores and all their clerkship shelf and clinical exam scores except Surgery were equivalent to those of their peers (Table 4).
Seven TRIUMPH students who enrolled in 2010 commented during their M4 focus group that the longitudinal fourth-year preceptorship, the mentoring by TRIUMPH faculty and staff, and the humanism rounds were especially effective in preparing them to work in underserved urban communities. They recommended offering similar sessions to all medical students. On the fourth-year survey they reported spending an average of 130 hours on projects (range: 82–248); they indicated that community projects were rewarding and that the duration of time allowed for these (15 months) allowed them to overcome setbacks and see progress.
All eight of the TRIUMPH graduates from this cohort selected residency programs in medically underserved urban areas: four in family medicine, two in pediatrics, one in medicine–pediatrics, and one in emergency medicine. Two of the students completed master of public health degrees during the year between graduation and residency.
Outcomes for the students who enrolled in TRIUMPH in 2011
Of the eight students who enrolled in the 15-month version of TRIUMPH in 2011, seven graduated in 2012, and one student has deferred graduation until 2013 for family medical leave.
TRIUMPH’s activities—especially the two-week intensive courses, the faculty and staff mentoring, and the community health projects—boosted their urban health knowledge, community health and advocacy skills, and their commitment to and confidence in working with urban underserved populations (Tables 2 and 3).
According to the comments these students provided during their M3 and M4 focus groups and on their M3 and M4 year-end surveys, the emotional, sociological, and logistical challenges that students faced in working with patients of lower socioeconomic status and with underserved communities during their Milwaukee experience taught them the importance of understanding and using community resources, patience with the process of development and change, and the need to find balance and to seek support when feeling overwhelmed. As one of these students commented, being in TRIUMPH got her “fired up” about a career in urban medicine and gave her “the tools to feel prepared” to work with underserved populations.
The seven students in this cohort performed as well as their SMPH peers in their courses in all four years of medical school as determined by their GPAs, and as well on their Step 1 and 2 board exams, clerkship exams, shelf exams, and clinical exams. This cohort of TRIUMPH students performed significantly better than traditionally trained peers on their year-end professional skills assessment at the end of Year 3 (Table 4).
All seven of the TRIUMPH graduates from this cohort selected residency programs in medically underserved urban areas: one in family medicine, two in internal medicine, two in pediatrics (one in a triple-board program in pediatrics, psychiatry, and child psychiatry), one in medicine–pediatrics, and one in emergency medicine. The eighth student from this cohort, who has deferred graduation until spring 2013, plans to enter a residency in family medicine.
In sum, across these two initial 15-month TRIUMPH cohorts, 87.5% (14/16) of the students have entered or plan to enter residencies in primary care specialties—a percentage about twice as high as for non-TRIUMPH graduates (44.1% in 2011; 42.9% in 2012)—and all who have graduated so far (14/15) have entered residencies serving urban, underserved populations
Early outcomes reveal that TRIUMPH has generated enthusiasm, reinforced values, strengthened skills, and influenced the attitudes and career choices of a select group of medical students to care for urban underserved populations. The TRIUMPH program, with 53 participants as of January 2013, has demonstrated successful short-term outcomes and will continue to assess short- and long-term impacts. Student and community mentor interest continues to exceed program capacity; student applicants and community projects outnumber spots available. Of the 15 students from the two 15-month cohorts that have graduated, 13 (86.7%) have chosen primary care residencies serving underserved urban communities. In addition, the student from 2011 who will graduate in 2013 also plans to go into primary care in an underserved community.
In every survey and focus group that has been conducted so far, students from all cohorts have consistently praised TRIUMPH, its activities, its administrators, and what they have learned and gained through their involvement. The few negative comments have focused on challenges with particular staff members, scheduling issues within clerkships, or community project assignments that were either too vague at first or that differed substantially from what the student expected. However, even in these latter cases, students felt that they learned important lessons about what is needed to develop relationships and create the foundation for long-lasting community health partnerships (most especially patience!). Comments from focus groups of students reflect that the program has reinforced their commitment to and increased their confidence in working with underserved populations and people of lower socioeconomic status. Students have shared that their attitudes shifted from helpless to hopeful, and that the program has preserved their spirit to work with underserved populations during the critical period of residency specialty selection. These sentiments are illustrated by one student’s statement:
I was interested in working with underserved populations, but TRIUMPH solidified this as my career goal and gave me the practical tools and confidence to be an effective community physician and advocate.
Further, TRIUMPH enhances the educational experiences of students and gives them an opportunity to work in underserved practices with positive role models who thrive in such settings. Medical students are familiar with memorizing facts, meeting precise course requirements, and practicing in clinical environments, yet most have limited experience working with communities and interdisciplinary teams to address complex, long-term problems. Carefully developed tools, flexible guidelines, and regular mentoring have enabled students to achieve progress, to enhance the capacities of host organizations, and to distinguish themselves as student leaders. One student notes:
Through TRIUMPH, I developed tools that helped me feel more confident and less concerned about burning out. My experiences learning to engage effectively with community health teams were particularly powerful.
Additionally, most medical students carry substantial educational debts and are concerned about how to balance their personal and family needs with careers dedicated to working with the poor and medically underserved. Exposing students to successful, enthusiastic physician role models and vibrant community health programs, informing them about loan repayment plans, and demonstrating the nonfinancial rewards related to working with disadvantaged populations provide them with viable career options.
The idea of working with this population doesn’t seem as daunting as it once did. I feel much more well rounded. I look at all the opportunities that TRIUMPH presented in working with the community … those are important skills to have as a physician that I wouldn’t be anywhere near having … without the experience of TRIUMPH.
TRIUMPH has also influenced the host institutions, including the UW SMPH itself. One advisory committee member has noted that the program has “actualized the school’s mission of social responsibility, provided new curriculum tools to prepare students to serve as health advocates, applied asset-based approaches to community health, and promoted self-reflection.” TRIUMPH is influencing the general curriculum and engaging additional faculty and students. For example, all students statewide now participate in humanism rounds through videoconferencing during their obstetrics–gynecology clerkship. In 2012, the UW SMPH was awarded an HRSA educational training grant to develop a new UW–Public Health and Primary Care Innovations in Medical Education program. Many of the ideas for this grant were derived from TRIUMPH.
TRIUMPH is beginning to influence residency programs, too. Graduates have initiated efforts to enhance community engagement at the postgraduate level. To illustrate, three TRIUMPH graduates who are enrolled in the Aurora family medicine training program in Milwaukee are spearheading efforts to strengthen the community health curriculum and outreach efforts of the residency. Finally, TRIUMPH improves community organizations as well. One community mentor has noted that TRIUMPH has fostered win–win partnerships with local organizations, enhanced the capacity of community partners, sowed seeds for future workforce recruitment, and forged new relationships with federally qualified community health centers.
Although this report describes the TRIUMPH program and its short-term outcomes, it does not fully convey the excitement, the enthusiasm, and the depth of the impact these experiences have on our students, institution, and community partners. Students, community mentors, and institutional partners alike are deeply satisfied with the program.
Although TRIUMPH has achieved notable short-term successes, the program has encountered significant conceptual, logistical, and financial challenges. A conceptual barrier is the reality that relatively few physicians have successfully integrated clinical medicine and public health into their careers. Therefore, recruiting physicians as well as other community health leaders to serve as student mentors and role models has been essential. Logistically, the medical school curriculum is overcrowded with content, requirements, and duty hours, so clear and regular communication with clerkship directors has been necessary to protect student time, to deliver content efficiently, and to demonstrate that community and public health work would enhance and not adversely affect students’ clinical performance. Financially, the program was launched at about the same time as the economic recession and at a time when the school was facing serious budget shortfalls due to reductions in state funding. Nevertheless, the school and the state have sustained their financial support. In fact, because of strong student, faculty, and community interests, the program even expanded during this period of strained resources.
We acknowledge the limitations of these early findings from a young program. TRIUMPH, like many programs designed to prepare students to work with underserved populations, faces evaluation challenges related to selection bias, the extensive follow-up required to identify students’ ultimate specialty and geographic choices, the need for sufficient sample sizes, the lack of randomized comparison groups, and limited preimplementation outcome comparison data. Because TRIUMPH enrolls SMPH students who already demonstrate a strong interest in urban underserved medicine, it will always be difficult to measure whether students with similar interests who do not enroll in the program do as well on certain outcome measures as TRIUMPH students. Nevertheless, TRIUMPH has demonstrated successful short-term outcomes indicating that it reinforces and sustains the commitment and improves the skills of medical students who want to care for urban underserved populations. Additionally, TRIUMPH serves as a testing ground for curricular innovation that can influence the entire curriculum. We plan to refine and expand the program, recruit more underrepresented minority students, continue to assess short- and long-term outcomes, and use those outcomes data to ensure quality and sustainability in the years to follow.
Although supportive health care systems, policies, and financing mechanisms are certainly required to ensure that physician graduates will be recruited and retained in areas of greatest need, medical education programs targeted to address the needs of underserved communities are also vital to prepare a socially responsive health professional workforce. Careful selection and preparation of future physician leaders who are committed to addressing the needs of the medically underserved will help to create a health professional workforce that can address the needs of the entire population. TRIUMPH’s early outcomes lead us to conclude that the program is a successful model to prepare future physician leaders to promote the health of urban underserved communities.
Acknowledgments: The authors appreciate the contributions of the Training in Urban Medicine and Public Health (TRIUMPH) program advisory committee members: Alex Adams, Sharon Adams, Ruric Anderson, John Bartkowski, Michelle Buelow, Shobhina Chheda, Lynne Cleeland, David Deci, Angelica Delgado, Jonathan Dickman, Rene Farias, Ann Getzin, Brenda Gray, Gina Green-Harris, Brian Hilgeman, Barbara Horner-Ibler, Paul Hunter, Tito Izard, Mark Kaeppler, Patrick McBride, Steven Murphy, Steve Ohly, Erica Pettke, Elizabeth Petty, Kim Puterbaugh, Patrick Remington, Christine Seibert, Kathy Stewart, Anthony Sturm, Nancy Sugden, Geoffrey Swain, Senait Tesfai, Jessie Tobin, Madelaine Tully, and Julie Usatinsky.
The authors wish to thank their outstanding community partners: Aurora Health Care, Bread of Healing, Center for Urban Population Health, Children’s Health Alliance of Wisconsin, City of Milwaukee Health Department, City on a Hill Free Clinic, Community Advocates, Core/El Centro, Lifecourse Initiative for Healthy Families, Milwaukee Area Health Education Center, Milwaukee County Breastfeeding Coalition, Milwaukee Center for Independence, Milwaukee Health Services Inc., Milwaukee Public Schools, Planning Council, Progressive Community Health Center, Sixteenth Street Community Health Center, United Community Center, Walker’s Point Community Clinic, Walnut Way Conservation Corporation, and Milwaukee communities and residents.
The authors thank Shafik Dharamsi, William Ventres, Elizabeth Petty, and Anne Dopp for their reviews, R. Lee Frederick for his enduring support, Mary Temby for her able assistance with preparation of the manuscript, and Kathy Musack for her skillful administration of the program. The authors appreciate the courage of the TRIUMPH students who pioneered and shaped this program.
Funding/Support: The TRIUMPH program is funded by the State of Wisconsin and the University of Wisconsin School of Medicine and Public Health.
Other disclosures: None.
Ethical approval: The University of Wisconsin institutional review board granted the TRIUMPH program evaluation an exemption.
Previous presentations: Earlier versions of this article were presented at the Society of Teachers of Family Medicine (STFM) Predoctoral Meeting in San Diego, California, February 2, 2012, and at the STFM Annual Meeting in Seattle, Washington, May 5, 2012.