1. Training Medical Students to Care for Underserved Patients A Preliminary Analysis Laura Hill-Sakurai MD Margo Vener MD, MPH Beth Wilson MD, MPH Kristen Kelly MPH, MS-IV (Presenter) Ralph Ermoian, MD

2. Topics of Presentation 1. Clerkship pilot program focusing on urban underserved 2. Preliminary evaluation data: What factors increase interest in underserved care within medical school?

3. Rationale for Pilot  UCSF medical school curricular changes in clinical years  Increasing awareness of health disparities  Cuts in Medicare and Medicaid funding  Increasing numbers of uninsured and underinsured in United States Model San Francisco General Hospital

4. Longitudinal Training at SFGH  San Francisco General Hospital  County hospital –Uninsured, underinsured patients –Large homeless population –Substance abuse –Immigrants and refugees

5. Pilot Program 2005-2006  20 students  3 of 6 clinical clerkships (Pediatrics, Medicine, Family Medicine) during 3 rd year  Longitudinal clinic with underserved population  Evening enrichment sessions  Mentorship with faculty who work with underserved

6. Goals for Pilot Program For underserved care:  Strengthen commitment  Develop skills and knowledge  Identify role models  Provide mentorship Additional Benefits:  Peer support  Continuity of location and patient care

7. Evaluation Research What factors increase interest in underserved care within medical school?

8. Methods  Mixed methods qualitative and quantitative  Pre- and post-surveys  Qualitative interviews of 22 students –First set after 1 st block –Second set after final block –Pilot and non-pilot participants

9. Data Collection/Analysis  Qualitative Interviews –Convenience sample –30-45 minute semi-structured interviews –Gift certificate incentive –Assurance of confidentiality  Analysis Methods –Content analysis using N-Vivo®

10. Semi-Structured Interview  10 questions including: –Attractions to the pilot –Factors increasing interest in working with underserved –Role models for working with underserved –Addressing health care disparities

11. Preliminary Themes 1. Factors that attract students to pilot 2. Avoiding pilot 3. Sustaining Interest 4. Discouragement/Burn Out 5. Synthesizing care

12. #1: Attracting Students to Pilot  Previous interest in underserved  Desire to work with underserved patients  Colleagues –Smaller cohort of students –Desire to work with “like-minded individuals”  Clerkship Logistics –Stay at one site for 6 months –Rotations at popular site –Like being in pilots: more attention

13. Colleagues “And then the other thing was the cohort of students…I thought that there'd be other really cool students that would have the same interests as me... Not so much the other kids in my class that want to work in Marin only…”

14. #2: Avoiding the Pilot  Wanted a mix of hospital sites  Wanted a mix of patient populations – not just underserved  Did not learn about pilot in time to apply

15. #3: Sustaining Interest  Patient Interactions –Witnessing inequalities in care –Hearing patients’ stories –Working with diverse and challenging patients –“This is something I can do”

16. More on Sustaining Interest  Role Models –Individuals who inspire or provide examples of working well with underserved –Longitudinal clinical experience  Extracurricular activities involving social justice or work with underserved  “Community of Students”

17. “This is something I can do” [I was] worrying, am I gonna be able to handle this…And so after six weeks in pediatrics at the General…Half of my patients, the interview's in Spanish and Chinese, and lots of the issues … have to do with their insurance, with their living situations, home visits - what are the social conditions that trigger asthma in these kids…So - just sort of getting a taste of that, and sort of seeing it in practice…I guess I’m just reassured that this is something that I can do, that I still want to do…

18. #4: Discouragement or Burn-Out  Logistics of providing care for underserved  Interactions with patients –Cultural and language barriers –Unpleasant experiences –Unappreciative patients –Complexity of problems –Feeling manipulated or abused  Expense of medical education

19. Unpleasant  I feel really bad about it [that experience], because it was not the patient's fault. He was actually a patient who had come in because of incontinence…he could not stop…peeing on himself during the entire…experience. And it was very…smelly, and I was getting his pee on me, and so..I was just like, wow, I don't know if I can do this.

20. #5: Synthesizing Care  Approach to care that integrates social factors fluidly with biological  No distinction when approaching patients  May help students work more effectively with underserved patients From UCSF Department of FCM Website

21. Examples – Synthesizing “…my first concern is that…there may be some things that we might not be getting, so I'd first ask if we could…bring in an interpreter. I'd want to … elicit her own rendition of the history which I've gotten here from the note about her dizziness. And then I would ask her about her social situation - where she lives, who she lives with, support that's around, her immigration from El Salvador and any concerns that she has about her social setting.”

22. Summary  Exciting new pilot  Qualitative data as way to understand student experiences  Plan to use this understanding to nurture student interest in underserved care

23. Questions to Ponder  Will pilot give impression that underserved care is equated with primary care only?  How do we ensure that students not in the pilot get encouragement to work with underserved?

24. Next Steps: Evaluation  Finish evaluation and analysis of pre- clerkship data  Collect post-clerkship data  Synthesis of data

25. Next Steps: Model SFGH  Assign individual mentors  Pre-clerkship orientation –Skill building –Introduction to hospital and community clinic system  Increased peer collaboration on project  Next year 25 spots due to high demand

26. Thank you!  Rick Haber, MD, Medicine  Alma Martinez, MD, Pediatrics  Michelle Schneiderman, MD, Medicine  William Shore, MD, FCM  Arianne Teherani, PhD  Paula Fleisher