1. Pipeline Issues: How to Get the Right People Into the Practices that Make a Difference Scholarship in Medicine Series Maine Dartmouth Family Medicine Residency Harold Alfond Center for Cancer Care July 26, 2011 Donald Kollisch, MD Deputy Dean for Academic Affairs Sophie Davis School of Biomedical Education at The City College of New York

2. Which Practices “Make a Difference” ? Are located in the right place geographically Have systems in place to respond to community needs Have financial incentives well-aligned with best-practices Fit into broader systems of care (regional, state, national)

3. Theoretical Models for Practices that Make a Difference Community Oriented Primary Care Community Oriented Primary Care Patient-Centered Medical Home Patient-Centered Medical Home

4. Examples of Practices that Make a Difference FQHC’s FQHC’s RHC’s RHC’s Hospital/State sponsored CHC’s Hospital/State sponsored CHC’s

5. Who are the “Right People” Personal characteristics Personal characteristics Attitudes well-aligned to practices that care for underserved communities Attitudes well-aligned to practices that care for underserved communities Dedicated Dedicated Compassionate Compassionate Patient Patient Flexible Flexible

6. Who are the “Right People” Training characteristics Training characteristics KnowledgeKnowledge SkillsSkills Social attributes Social attributes Rural/UrbanRural/Urban EthnicityEthnicity GenderGender

7. Rural Health Pipeline Admissions Medical school Retention Residency Choosing a practice Practice Residency selection Rural Doctor Primary care -Family Med -Internal Med -Pediatrics Surgery Ob-Gyn Psychiatry ….others.. Decision to be a Doctor Family Middle School High School College

9. Recommendations from Executive Summary Create more opportunities for students and young physicians to trade debt for service, through effective programs such as the National Health Service Corps. Reduce or resolve disparities in physician income. Admit a greater proportion of students to medical school who are more likely to choose primary care, rural practice, and care of the underserved. Study the degree to which educational debt prevents middle class and poor students from applying to medical school and potential policies to reduce such barriers.

10. Shift substantially more training of medical students and residents to community, rural and underserved settings. Support primary care departments and residency programs and their roles in teaching and mentoring trainees. Reauthorize and revitalize funding through Title VII, Section 747 of the Public Health Service Act. Study how to make rural areas more likely practice options, especially for women physicians. New medical schools should be public with preference for rural locations.

11. What is missing? The earlier portion of the pipe. Who are the people who go to medical school?

12. How do the right people get to BE the right people? Genes Up-bringing (family, community) School K-12 College Medical Residency

14. Pipeline What are the pathways – for it is not a single pathway - by which (young) people end up as Primary Care doctors for the Rural and Urban Underserved? Which level(s) of the pipeline are crucial? How can we keep the big picture in mind?

15. Pipeline

16. Pipeline 2

17. Mission of Sophie Davis School Provide access to medical education for youth from under-represented minorities and economically- disadvantaged families Provide access to medical education for youth from under-represented minorities and economically- disadvantaged families Promote careers in Primary Care Promote careers in Primary Care Promote careers in Underserved Communities Promote careers in Underserved Communities Provide an excellent educational program to prepare learners to enter clinical training Provide an excellent educational program to prepare learners to enter clinical training

18. Special Features of Sophie Davis Special Features of Sophie Davis Students admitted straight out of high school – recruiting and pipeline programs Students admitted straight out of high school – recruiting and pipeline programs Students agree to provide 2 years’ primary care service in a physician shortage area of New York State after completing residency – primarily urban Students agree to provide 2 years’ primary care service in a physician shortage area of New York State after completing residency – primarily urban Approximately 20% attrition (voluntary or dismissed) Approximately 20% attrition (voluntary or dismissed)

19. Unique Structure and Curriculum: 7 year combined BS-MD First 5 years at City College on our Harlem campus, with components of Baccalaureate PLUS the “basic sciences” which usually comprise the first 2 years of Medical School First 5 years at City College on our Harlem campus, with components of Baccalaureate PLUS the “basic sciences” which usually comprise the first 2 years of Medical School Final 2 years at one of 6 “cooperating” schools: Albany, Dartmouth, Downstate, New York Medical, NYU, Stony Brook Final 2 years at one of 6 “cooperating” schools: Albany, Dartmouth, Downstate, New York Medical, NYU, Stony Brook

20. Sophie Davis Curriculum Physical Diagnosis Step12 Introduction to Medicine Step11 Systemic Pathology Step 10 Neuropsychiatry Step 9 Host Defense, Infection and Pathogenesis Host Defense, Infection and Pathogenesis Step 8 Pharmacology Pharmacology Step 7 Behavioral Medicine Behavioral Medicine Step 6 Systemic Functions Systemic Functions Step 5 Neuroscience Neuroscience Step 4 Structure Structure Step3 Molecules to Cells Step 2 College courses, including pre- med requirements College courses, including pre- med requirementsStep1 Community Health Community HealthCOPC Patient-Doctor (interviewing)

21. Diversity Why is diversity an issue? Social equity and fairness Historically, middle and upper class white doctors tend to practice in the social communities from which they came And, historically, doctors from minority communities tend to practice in the social communities from which THEY came A diverse class in school and residency can be an important component of social education AAMC: “Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical professions relative to their numbers in the general population.” (2004) How fine is the definition cut? Does “Low-income” count? YES!

22. Diversity at Sophie Davis Ethnicity: 1/3 African-American 1/3 Asian-American (South and South-East) 1/6 Latino-American (Dominican, Puerto Rican, South America) 1/6 Caucasian Gender: 60-65% female 35-40% male Low-income: 32% from families below 100% of the FPL 75-80% are eligible for Financial Aid at City College (where tuition/fees are $5,000/year) Immigrant 25% First-generation 57%

23. Challenges and Lessons Learned Of the 20% who leave Sophie Davis, ¾ are URM Students who come from at-risk communities have extraordinary social as well as academic challenges Each Cooperating School wants >1/2 of “their” transfers to be URM and from the upper half of the class Students from “humble origins” are perceived by Cooperating Schools as beneficial to their schools, even if not URM One of the ways to get away from the poor predictive value of MCATs and college GPAs is to get away from MCATs and GPAs Dissemination of this model is limited by availability of Clerkship slots, especially facing competition from Caribbean schools

24. Sophie Davis in the Pipeline

25. Can we generalize from Sophie Davis to the needs of Rural Maine? What are the pipeline programs of Maine? AHEC FAME - Financial Maine Health Professions Loan Program Doctors for Maine’s Future Scholarships – Tufts/MMC or UNECOM Exposure – the “Cambridge” model in smaller rural hospitals via Tufts/MMC Service Obligation? “Binary” program – BS/DO (UoM/UNECOM) Who else is working on the pipeline earlier than college?

26. Who is working on the Pipeline in Maine?