The Martin Luther King, Jr. Medical Center and the Charles R. Drew University of Medicine and Science provide care for one of the most impoverished populations in Los Angeles County. The results of this study suggest that the UCLA/Drew Medical Education Program has been preparing physicians in accordance with the Drew mission. Our findings are consistent with those for the Jefferson Physician Shortage Area Program (PSAP), which has demonstrated that after controlling for rural background and premedical interest, PSAP graduates are more likely to become rural family physicians.9
No factor has been as strongly linked service to the underserved as minority race/ethnicity. In this study, we found that after controlling for URM status, Drew graduates have greater odds of practicing in disadvantaged communities. We propose that an inner-city-based program may have a reinforcing effect on those students initially inclined to work in these communities.
As does the PSAP, the UCLA/Drew Program contains two main nontraditional components: first, an admissions process that emphasizes applicant commitment to service; and second, longitudinal clinical experiences in the target community. The Drew admissions committee assesses applicants’ involvement in community service, leadership potential, motivations, understanding of the needs of underserved populations, and the maturity and clarity of their career goals. In a previous study on student intentions, we found that students in UCLA/Drew program showed increased commitment over the course of medical school in contrast to their UCLA classmates with the same initial career goals, who experienced a decline in interest.14
In conjunction with our present findings, this suggests that the program’s success may be attributable in part to the selection and development of exceptionally motivated students.
Medical programs can provide a supportive environment for students in a number of ways. Although short-term rotations have no demonstrated effect, cumulative experiences during medical training predict family medicine residents’ intent to practice in underserved areas.19
After their first 2 years of basic science instruction at UCLA, students complete core clinical rotations at the King/Drew Medical Center (KDMC), participate in a longitudinal primary care clinic in a neighborhood health center, and conduct a research thesis specific to disadvantaged populations. As a result, students spend a majority of their clinical time in south Los Angeles and through their experiences, develop ties to the patient population and community. In addition, Drew students’ goals may be further nurtured and reinforced through interactions with like-minded peers and faculty. Furthermore, the student body at Drew is quite diverse, with ~70% of students being of URM backgrounds. Students in medical schools with greater racial diversity have more favorable attitudes to underserved populations.20
One of the strengths of the present study is the robustness of the findings across several indicators of “medically disadvantaged areas.” The most common measures are federally designated “Health Professional Shortage Areas” (HPSAs) or Medically Underserved Areas (MUAs), but these classifications may have limited validity as indicators of community-level need. The HPSA “special population” criterion does not include groups with persistent health care access problems such as minorities other than Native Americans, and although under consideration, revised designation methods have yet to be formally adopted. We find these concerns especially pertinent to this study, because until recently, only the King-Drew medical facility received the HPSA designation, and not the surrounding poor, minority, inner-city community. Therefore, we expanded our measures beyond the HPSA designation to include minority and high-poverty populations and found again that Drew graduates had greater odds of practicing in disadvantaged areas than their UCLA counterparts. We found no relation between the Drew program and practice in rural areas—which, given the urban location of the program, was expected.
In the attempt to evaluate the efficacy of a program with a broadly stated mission, we encountered several limitations. The definition of medically “underserved” or “disadvantaged” area has not yet been operationalized for research at the national level, thus, restricting our analysis to California. We cannot dismiss the possibility that these physicians limited their practices to serving higher-income subgroups in their practice areas, but given the stringency of the outcome criteria, the vast majority of the population is likely to be medically disadvantaged. Nearly one-third of physicians did not complete the Prematriculation Questionnaire (PMQ), which limited our ability to account for socioeconomic background. We were also unable to determine if a graduate grew up in an underserved area, instead, using a type of high school community as an approximation of childhood environment. Furthermore, we did not assess student intentions before medical school, and thus, acknowledge an inherent selection bias in the type of student who chooses to enter the program. It is not feasible to conduct a randomized controlled trial or compare students with applicants who were accepted but chose not to enter the program. Because this study addressed two medical education programs in Los Angeles, the results may not be generalizable to other programs across the nation. Therefore, we limit our conclusions to suggest that the success of the program may be attributed significantly to the selection and training of exceptionally driven students. Overall, this study represents an important first step in illustrating the potential of medical education to shape physician supply and distribution.
The next step would be to examine the practice patterns of the graduates throughout the nation, including teaching and research activities that may also be aimed at health care inequities. Career paths have yet to be described, e.g., whether physicians practice in disadvantaged areas after their careers have been established or if increasing financial obligations or physician burnout lead to an exodus from these areas. Ideally, policymakers and educators would be able identify the key factors to retain physicians in underserved communities for the duration of their careers and demonstrate that having dedicated local care providers improves health outcomes.
As state initiatives have drastically reduced schools’ ability to ensure adequate minority student enrollment,21
the need to train committed physicians to serve poor and minority communities is perhaps greater than ever. We believe the UCLA/Drew Medical Education Program can serve as a model for other institutions to counter persistent disparities in access to physician services along lines of race, ethnicity, income, and geography.