Charles R. Drew University of Medicine and Science - College of Medicine Health Care Disparity: The Drew Response May 25, 2005 Charles R. Drew University of Medicine and Science

Charles R. Drew University of Medicine and Science - College of Medicine Charles R. Drew University of Medicine and Science Mission Statement To conduct medical education and research in the context of community service in order to train physicians and allied health professionals to provide care with excellence and compassion especially to underserved populations

Charles R. Drew University of Medicine and Science - College of Medicine Charles R. Drew University of Medicine and Science u Lack of accessible health care identified as contributing factor to Watts riots u McCone Commission recommends general teaching hospital be established u Charles R. Drew Postgraduate Medical School founded as academic partner of the Martin Luther King, Jr. County Hospital u Drew incorporated as a private, non-profit educational institution

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine u July 1971: First contract between Los Angeles County and Drew Postgrad. Med. School for provision of health care and educational services at the King Hospital- MLK-Hospital opens in u May 1978: Drew/UCLA undergraduate medical student education program for M.D. degree established by California Bd. Of Regents

Charles R. Drew University of Medicine and Science - College of Medicine Charles R. Drew University of Medicine and Science –1985: Population: 350,000 – Geographic area: 33 square miles – Racial Composition: 81% black –Current: Population: 1.5 million (SW Cluster) – Poverty Level (31.8%) – Geographic area: square miles – Racial Composition: 23.3% Black – 59.7% Latino, 5.4% Asian/Other

Charles R. Drew University of Medicine and Science - College of Medicine Charles R. Drew University of Medicine and Science u A non-profit institution accredited by the Western Association of Schools & Colleges u Individual programs accredited by appropriate accrediting body u Comprised of: ã The College of Allied Health ã The College of Medicine ã Post-graduate Physician Education ã Educational Pipeline ã Community programs

Charles R. Drew University of Medicine and Science - College of Medicine The Charles R. Drew University of Medicine and Science u Faculty: College of Medicine: 250 Academic track 150 Clinical track

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine Undergraduate Medical Education Continuing Medical Education Graduate Medical Education Community Service Research Clinical Service

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine Accreditation of College of Medicine and King Drew Medical Center Liaison Committee on Medical Education Joint Commission for Accreditation of Health Care Organizations Accreditation Council of Continuing Medical Education Accreditation Council for Graduate Medical Education

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine Undergraduate Medical Education u Joint MD Program with UCLA u 24 Students Each Year (96 Total) ~1800 Applicants Each Year u 1st/2nd Year (Basic Sciences) Training at UCLA 3rd/4th Year (Clinical Sciences) at Drew/King Campus u Primary Care Curriculum with Primary Care Research Requirement u Learning Resources Center/Medical Informatics

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine Graduate Medical Education u Residents u Residency Programs u Oral Surgery u Orthopedic Surgery u Otolaryngology u Pediatrics u Psychiatry u Anesthesiology u Dentistry u Dermatology u Emergency Medicine u Family Medicine u Internal Medicine u Obstetrics & Gynecology u Ophthalmology

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine Medical Education u Primary Teaching Sites –King/Drew Medical Center –Ambulatory Care Sites –Hubert H. Humphrey Comprehensive Care Center –T.H.E. clinic –University Muslim Medical Associates Free Clinic

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine Research Changing NIH guidelines now mandate that ethnic minorities comprise a proportion of studies that reflects their number in the general population u Nationally-recognized for research concerning historically understudied groups u Public policy influence u Collaborative research efforts with other institutions

Charles R. Drew University of Medicine and Science - College of Medicine College of Medicine Minority Health Initiatives: u Alcohol & Drug Abuse u Perinatology u Cancer u Violence/Trauma u Hypertension/Cardiovascular Disease u Diabetes u HIV/AIDS u Aging Existing Infrastructure: u Basic Science Initiative u Clinical Research Centers u Clinical Trials Unit u Research Centers in Minority Institutions (RCMI) u Telemedicine Project Research * * * *Funding Priorities * *

RCMI Impact on Research at Drew NIH Funding: $5,762,903 in 1997 to $19,990,406 in 2002 NIH Awards to Southern California Institutions by Rank in FY 2002 *Rank of institution based on total NIH funding in FY 2002 (last available). Sources:

Health Record Knowledge Resource Guidelines Research Expert System Data from the “world outside” individual patient James J. Cimino, M.D - NLM source of slide

Charles R. Drew University of Medicine and Science - College of Medicine Volume 348: June 26, 2003 Numb er 26 Improving the Quality of Care — Can We Practice What We Preach? Earl P. Steinberg, M.D., M.P.P. It has been 30 years since Wennberg and Gittelsohn published their landmark article demonstrating substantial variation …….From the perspective of the quality of care, the variation that is the greatest cause for concern is that between actual practice and evidence-based "best practice."

Charles R. Drew University of Medicine and Science - College of Medicine National Report on Health Care Disparity

Charles R. Drew University of Medicine and Science - College of Medicine Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Quality of Health Care Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care--- (source of slide Institute of Medicine-Unequal treatment) Populations with Equal Access to Health Care

Charles R. Drew University of Medicine and Science - College of Medicine Recent Health Trends in Los Angeles County Office of Health Assessment and Epidemiology Los Angeles County DHS Source of slide March 6, 2003

Charles R. Drew University of Medicine and Science - College of Medicine Health Indicator Rankings, South and West SPA’s: Examples of Geographic Clustering Office of Health Assessment and Epidemiology-County of Los Angeles

Charles R. Drew University of Medicine and Science - College of Medicine Accreditation Council for Graduate Medical Education u Scholarly Activity-Graduate medical education must take place in an environment of inquiry and scholarship in which residents participate in the develop of new knowledge, learn to evaluate research findings and develop habits of inquiry as a continuing professional responsibility.

Charles R. Drew University of Medicine and Science - College of Medicine Practice-Based Learning and Improvement (Source ACGME ) u Analyze practice & improve using a systematic methodology u Locate, appraise & apply scientific evidence u Apply knowledge of study designs & statistics u Obtain & use patient population data u Use information technology u Facilitate the learning of others

Charles R. Drew University of Medicine and Science - College of Medicine Evaluation by others  deficit in delivering bad news Identify Improvement Needed Engage in Learning Apply Learning Check for Improvement     Example 1: Use evaluations by others to improve own skills (slide ACGME website) Read & appraise studies ; view video; role play Perform new skills Evaluation by others

The Future of Medicine-Drew is a member of INTERNET 2 HEALTH INFORMATION SUPERHIGHWAY Drug Companies Medical Manufacturers DatabasesHospitals Patients at home Government Insurers Medical Schools Doctors

Charles R. Drew University of Medicine and Science - College of Medicine Health Workforce u California –Ranks 50 th in nation for nurses per 100,000 pop. –Ranks near bottom (40 th – 49 th ) for mental health, therapists, technicians, and auxiliary health aids –Ranks 15 th in nation for physicians »194.5 physicians per 100,000 (US 197.5)

Charles R. Drew University of Medicine and Science - College of Medicine Health Professional “Mal-distribution” u Physician surplus in California –Distribution creates a dichotomy »21% of urban zip code clusters – below threshold »42% of rural zip code clusters - below threshold »+ association with income u Stronger association with African American and Latino communities »100% of impoverished AA communities are below threshold * »82% of impoverished Latino communities are below threshold * * Grunbach, et al Komaraory, 1996

Charles R. Drew University of Medicine and Science - College of Medicine California Physicians u California relies on other states and on foreign schools to train most of the physicians that practice in the state. –51% trained in a state outside California –22% trained outside of the US

The Survey Distributed to three classes Demographics Specialty choice Practice characteristics Obligations Evaluation of job market

Charles R. Drew University of Medicine and Science - College of Medicine Medical Graduate Evaluation u Affiliated programs / sponsoring schools –UC - Programs (2248) »UC-Davis School of Medicine (443) »UC-Irvine School of Medicine (327) »UC-Los Angeles School of Medicine (549) »UC-San Diego School of Medicine (311) »UC-San Francisco School of Medicine (604) –Non-UC Programs (930) »University of Southern California Medical Center (466) »Charles King Drew University of Medicine (128) »Loma Linda University Medical Center (237) »Stanford University Hospital (89)

Practice Location

Charles R. Drew University of Medicine and Science - College of Medicine Practice Location Demographics u Affiliated programs varied widely as to location demographics of their IMG and USMG residents »Drew (44%), UCLA (35.9%), USC (42.7%), and UCSF (39.4%) had the highest percentage of IMGs entering rural and inner cities combined (p<0.005) »UCSF and Drew had the highest percentage of USMGs entering rural and inner city practice locations (30.1% and 28% of USMGs respectively )(p<0.005)

Charles R. Drew University of Medicine and Science - College of Medicine Practice in California u There was no significant variation amongst the USMGs and IMGs of the different affiliations, for plans to practice in or out of the state »Drew (89.4%), UCSF (84.3%), and USC (85.7%) had the highest percentage of IMG residents planning to stay in California »UCLA (80%) and UCI (83.3%) had the highest percentage of USMGs planning to stay in California

Charles R. Drew University of Medicine and Science - College of Medicine Practice Type u Predilection to practice in an underserved setting (VA, city / county, state hospitals or public health centers/clinics) was also variable »LLU (54.5%), UCI (54.5%), UCSD (54.5%), and UCSF (50%) had the highest percentage of IMGs entering these areas »Drew (48.6%), UCSF (41.6%), LLU (40%) had the highest % of USMGs entering those practice types

Charles R. Drew University of Medicine and Science - College of Medicine Discussion u Association with practice characteristics and program sponsor or affiliated institution was variable. »Weakened by limitations discussed below »Some trends seen – Drew and UCSF produce the highest percentage of their own residents that then pursue practice characteristics that will favor alleviating the mal- distribution in California

Figure 2. Do you Plan to Work in an Underserved Area? DREW Matriculation Questionnaire N=4N=20N=4N=20 Graduation Questionnaire Yes N (%) N = 63 (68.5%) No/ Undecided N = 29 (31.5%) Yes N = 228 (28.1%) No/ Undecided N = 583 (71.9%) Yes N (%) N = 79 (86%) No/ Undecided N = 13 (14%) Yes N = 160 (20%) No/ Undecided N = 650 (80%) UCLA Decision to practice in underserved communities