Commitment to the underserved: evaluating the effect of an extracurricular medical student program on career choice

Medical students attitudes toward and intention to work with the underserved: a systematic review and meta-analysis

BACKGROUND

Experts in the field of medical education emphasized the need for curricula that improve students' attitudes toward the underserved. However, some studies have shown that medical education tends to worsen these attitudes in students. We aimed at systematically reviewing the literature assessing the change in medical students' attitudes toward the underserved and intention to work with the underserved throughout medical education, the sociodemographic and educational factors associated with favorable medical student attitudes toward and/or intention to work with the underserved and the effectiveness of educational interventions to improve medical student attitudes toward and/or intention to work with the underserved.

METHOD

We conducted a systematic review on MEDLINE, Scopus, and Web of Science databases. Three investigators independently conducted the electronic search. We assessed the change in medical students attitudes toward the underserved by computing a weighted mean effect size of studies reporting scores from validated scales. The research team performed a meta-analysis for the sociodemographic and educational factors associated with medical students attitudes toward and/or intention to work with the underserved.

RESULTS

Fifty-five articles met the inclusion criteria, including a total of 109,647 medical students. The average response rate was 73.2%. Most of the studies were performed in the USA (n = 45). We observed a significant decline of medical students attitudes toward the underserved throughout medical education, in both US and non-US studies. A moderate effect size was observed between the first and fourth years (d = 0.51). Higher favorable medical students attitudes toward or intention to work with the underserved were significantly associated with female gender, being from an underserved community or ethnic minority, exposure to the underserved during medical education and intent to practice in primary care. Regarding educational interventions, the effectiveness of experiential community-based learning and curricula dedicated to social accountability showed the most positive outcome.

CONCLUSIONS

Medical students attitudes toward the underserved decline throughout medical education. Educational interventions dedicated to improving the attitudes or intentions of medical students show encouraging but mixed results. The generalizability of our results is impeded by the high number of studies from the global-North included in the review.

Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review

PURPOSE

The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States.

METHOD

In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles.

RESULTS

Seventy-two observational or case-control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas.

CONCLUSIONS

Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.

Academic achievement and primary care specialty selection of volunteers at a student-run free clinic

BACKGROUND

Previous studies have reached conflicting conclusions about the associations between service and academic achievement and service and primary care specialty choice.

PURPOSES

This study examines the associations between service at a student-run clinic and academic achievement and primary care specialty choice.

METHODS

Retrospective review of medical student service and statistical analysis of grade point average (GPA), Step 1 and Step 2 Clinical Knowledge (CK) scores, and specialty choice were conducted, as approved by our Institutional Review Board.

RESULTS

Volunteers, compared to nonvolunteers, had higher GPA (3.59 ± 0.33 vs. 3.40 ± 0.39, p < .001), Step 1 (229 ± 19 vs. 220 ± 21, p < .001), and Step 2 CK (240 ± 18 vs. 230 ± 21, p < .001) scores, but did not pursue primary care specialties at a significantly higher percentage (52% vs. 51%, χ² = .051, p = .82).

CONCLUSIONS

Further exploration of the associations between service and academic achievement and primary care specialty choice is warranted.

Promoting sustainable community service in the 4th year of medical school: a longitudinal service-learning elective

BACKGROUND

To address the country's most pressing healthcare needs, medical students must choose careers in primary care and commit to working with underserved populations. Involvement in student service organizations has been shown to strengthen leadership, empathy, and commitment to underserved health and may lead students to pursue careers in primary care.

DESCRIPTION

In 2010, the University of Chicago Pritzker School of Medicine developed a novel 1-year longitudinal service-learning elective called SERVE (Service, Education, Reflection, Volunteerism Elective). Students earned elective credit for completing three course requirements: 10 service sessions, monthly reflections, and a service-learning project.

EVALUATION

One third of the class enrolled in the course (33/99), 25 students completed the course, and 20 completed the final evaluation. Both quantitative and qualitative analyses of the final evaluations demonstrated high satisfaction with the course, and appreciation of the opportunity to volunteer, teach, and develop service projects. SERVE students reported a strong commitment to continuing community service after graduation, with 100% planning to continue volunteering and 70% strongly agreeing with the statement that they would practice in an underserved community in the future. This commitment was higher than that expressed by the graduating class of 2012 (34%) and higher compared to a national average (30.9%).

CONCLUSIONS

SERVE is a unique 1-year course that reengages 4th-year medical students in service to their communities in a structured educational environment. SERVE students report that the course has increased their involvement in the community, supported their growth into a teaching role, and enhanced continuity within student-run free clinics. Future directions include assessing the impact of SERVE students on the experience of preclinical medical students in student-run free clinics; community response to SERVE projects; and the impact of SERVE on volunteerism, primary care specialty choice, and future practice in underserved communities for class participants during their medical careers.

Developing a novel Poverty in Healthcare curriculum for medical students at the University of Michigan Medical School

Nearly 90 million Americans live below 200% of the federal poverty threshold. The links between lower socioeconomic status and poor health are clear, and all physicians face the resulting challenges in patient care. Current medical school curricula do not adequately prepare students to address this issue despite recommendations from the Association of American Medical Colleges and the Institute of Medicine. In response, students and faculty at the University of Michigan Medical Center established the Poverty in Healthcare curriculum, which encompasses required learning experiences spanning all four years of undergraduate medical education. This article describes the design and implementation of this curriculum. The authors provide thorough descriptions of the individual learning experiences, including community site visits, longitudinal cases, mini-electives, and family centered experiences. The authors also discuss the history, costs, challenges, and evaluation process related to the Poverty in Healthcare curriculum, including issues specifically related to medical students' involvement in developing and implementing the curriculum. This information may be used as a guide for other medical schools in the development of curricula to address this current gap in medical student education.