Bailey, Jacob A.; Willies-Jacobo, Lindia J. MD
The University of California (UC) has long been challenged with identifying strategies to increase diversity amongst its various disciplines, including the health sciences. In 2007, a plan was developed to address this issue while simultaneously focusing on the need to increase the number of doctors specifically trained to work in California’s underserved communities.1 The proposition was to design a combined MD–master’s degree program that would train future leaders in medicine for underserved communities.
After approval from the university’s board of regents and receipt of a $200 million bond support, the five UC medical school campuses in Davis, Irvine, Los Angeles, San Diego, and San Francisco each established a distinctive cohort of the new Program in Medical Education (PRIME). The schools achieved this by increasing the number of matriculants at each campus. These programs were developed largely in response to recommendations made by the University-wide Health Sciences Committee as well as the Sullivan Commission on Diversity.2,3 Each campus adopted its own focus: rural medicine at Davis, Latino communities at Irvine, leadership in medicine at Los Angeles, urban underserved medicine at San Francisco, and health equity at San Diego. PRIME curricula on each campus included increased attention to health disparities and extended time for students to fulfill master’s degree requirements in a focus and location of their choice. The expectation was that these studies would complement traditional medical education and prepare students for physician leadership.
The flagship PRIME cohort began in 2004 at UC Irvine. It was named PRIME-LC for its commitment to serve local Latino communities. The design of the curriculum was based on community input to help future physicians engage Latinos in a culturally and linguistically appropriate manner.4 Among the traits required for students interested in this program were Spanish proficiency and understanding of Latino culture. By including a commitment to the community in its vision statement, PRIME-LC forged successful partnerships toward increasing matriculation of underrepresented minority (URM) students.5 In fact, URM students make up a high percentage of PRIME-LC matriculants. Other PRIME cohorts now demonstrate this trend as well. We suggest that these increased numbers are due to PRIME’s appeal to URM and disadvantaged students.
PRIME’s ability to achieve its goal of increasing the supply of physicians who care for California’s underserved communities may be interdependent on its ability to increase the number of students from URM and disadvantaged backgrounds at our UC campuses. To date, there has not been a formal assessment of PRIME’s influence on application and admission trends. We proposed using UC San Diego (UCSD) School of Medicine admissions data to evaluate PRIME–Health Equity’s (PRIME-HEq’s) effectiveness in attracting URM students. Our hypothesis was that URM students and those from disadvantaged backgrounds would be more likely than their non-URM and nondisadvantaged peers to apply to this program. Through simple statistical methods, we assessed how attractive PRIME-HEq is to URM students, who are more likely to adopt its mission and achieve its goals.
Data source and study sample
We reviewed applications to the UCSD School of Medicine for the entering classes of 2008 to 2010. Because of the nature of our study, we received IRB exemption from the UCSD human research protections program. We proceeded with data collection and analysis from June 2010 to March 2011.
In short, applicants submitted primary applications through the American Medical College Application Service (AMCAS) Web site, and select applicants were invited by UCSD to submit supplementary applications. At this point, students were able to indicate an interest in PRIME-HEq. Expressed interest in PRIME-HEq was the only requirement to be recognized as an applicant to the PRIME-HEq program during this period. Applicants who submitted secondary applications were considered for interviews. Those who interviewed were subsequently evaluated for admission and matriculation.
We analyzed only responses to the institution’s secondary application for this study. We excluded applications to specialized programs (e.g., Medical Scientist Training Program), those withholding demographic information, and partial applications. We compared applications to PRIME-HEq (n = 1,236) with the remaining applications (n = 3,178).
The nominal variables we included in the study were gender, disadvantaged status, California residency, prior submission of an application to UCSD, and URM status. Applicants self-reported disadvantaged status and ethnicity through the AMCAS application. The Association of American Medical Colleges (AAMC) recognizes various forms of disadvantage, including socioeconomic, educational, as well as cultural. For purposes of this study we did not differentiate varieties. In accordance with AAMC guidelines, we designated Hispanic/Latino, African American, Native American, and Native Hawaiian individuals as URM applicants. We included prior submission of an application as a variable in our model because individual applications, not applicants, were assessed. Our intent with this variable was to account for people who applied multiple times during the study period.
All of our statistical analyses were performed using Predictive Analytics SoftWare version 18 (PASW Statistics 18.0, IBM, New York, New York). We built a backward stepwise logistic regression model using significant independent variables and interactions we found with chi-square analysis. We removed interactions and main effects that were not significant before repeating a nonstepwise logistic regression. A Hosmer–Lemeshow test determined the goodness of fit of our final nonstepwise logistic regression results.
From 2008 to 2010, there was a significant difference (P < .0005) in the number of applications to PRIME-HEq based on disadvantaged status, URM status, and gender (see Table 1). Applications from disadvantaged students, those from students with URM backgrounds, and those from women were more likely to indicate an interest in PRIME-HEq than applications from nondisadvantaged students, non-URM students, and men, respectively. Although the mission of PRIME-HEq is to train physician leaders to care for California’s underserved communities, there was no significant difference between the rate of PRIME-HEq applications from California residents and non-California residents. Similarly, applications from individuals who had applied previously did not show a significant difference from first-time applications. When we compared applications from disadvantaged students and from students from nondisadvantaged backgrounds, we found significant differences (P < .001) between the two groups in URM status, gender, having applied previously, and California residency status (see Table 2). Comparing URM students and non-URM students, we found gender, having applied previously, and California residency status to be significantly different (P < .05) between the two groups. Comparing California residents with non-California residents, we found a significant difference (P < .05) in the rate of women applicants.
We used a backward stepwise logistic regression analysis to determine which of these independent variables and significant interactions would predict interest in PRIME-HEq (see Table 3). Our model showed disadvantaged status to be the greatest predictor of application to PRIME-HEq. Additionally, URM status and female gender were significant predictors. The effect of gender was attenuated, however, within the URM applicant pool.
Discussion and Conclusions
Our study supports the position that PRIME-HEq enhances diversity efforts. We were not surprised that a greater percentage of URM students than non-URM students self-identified as disadvantaged, nor that female gender and California state residency were associated with URM status (see Table 2). These statistics reinforce the need to address gender and ethnic inequities. That non-California residents were less likely to be disadvantaged may be due to higher tuition for nonresidents, thereby discouraging disadvantaged nonresidents to apply despite the availability of application fee waivers and need-based aid. Social factors that predispose disadvantaged status likely have negative effects on application competitiveness, thereby increasing the likelihood that disadvantaged students would need to apply more than once in order to be accepted. The preponderance of female applicants among URM students was notable, as we did not find the same phenomenon amongst non-URM students. Gender rates among URM students at undergraduate institutions and within premedical majors could explain this result.
The assumption that the PRIME-HEq curriculum enhances diversity efforts is not unfounded. Previous studies have suggested that curriculum greatly affects a school’s diversity. For example, when asked to evaluate a course on health care disparities, students at the University of Chicago ranked it highest amongst all classes.6 This same course influenced many URM students to matriculate to the school during a period of increased URM enrollment.7 A 2007 survey by the AAMC showed that whereas school curriculum influenced matriculation decisions of all applicants, student diversity was more important to URM matriculants than to non-URM matriculants.8 In fact, diversity has been shown to influence which schools students attend, how they perceive their training, and which residencies they choose on graduation.9–11
This relationship between curriculum and diversity appears to be part of a positive feedback loop in which the curriculum appeals to some URM applicants, thereby increasing ethnic diversity among students who enroll, which in turn increases the perception by URM applicants of a favorable school environment, leading to further increases of URM matriculants. PRIME attempts to fit this model while simultaneously promoting the development of physician leaders committed to underserved communities. To do this, UC has relied on data showing that URM students and those with greater exposure to underserved communities are more likely to practice in such areas.12 Likewise, students whose formative teenage years were in rural or high-minority areas are more likely to practice in these communities.13 In fact, the creation of rural health care programs has led to gains in the rural physician pipeline.14
PRIME’s addition of a master’s degree to formal medical education provides opportunities for students to develop skills that will assist them in leadership roles. When asked, community health center directors identified additional education as one way to better prepare and retain leadership.15 In another study, students who completed a master’s in public health degree between their third and fourth years of medical school expressed having developed skills in many of the same areas mentioned by the community health center directors.16 Likewise, a master’s in business administration degree was indicated as beneficial to physicians with dual degrees.17
Although qualitative data are currently lacking, our hypothesis is that all PRIME cohorts increase cultural congruity between the medical campus and students from URM and disadvantaged backgrounds. At the undergraduate level, cultural congruity and a feeling of belonging predict Latino student persistence and success in science, technology, engineering, and math (STEM) majors.18,19 Working for social change has been shown to be more important to URM students who leave STEM majors than to URM students who persist in these majors.20,21 For those students who transition into medicine, PRIME may be an enticing venue for developing that aspect of their social identity.
Although our overall findings are noteworthy, our study had limitations. Because we only evaluated secondary applications, we know little about how PRIME-HEq is affecting the applicant pool as a whole. Applicants who did not submit secondary applications did not have the opportunity to express an interest in PRIME-HEq. Also, we did not assess the effect the program may have had on applicants’ matriculation decisions. The effect of PRIME-HEq on current admissions trends is still largely unknown. This is partly because the program is still young, and its cohort sizes are small. However, its small size does make qualitative studies an attractive option for understanding factors that influence applicants.
The subtleties of PRIME-HEq’s effectiveness in attracting certain students may be influenced by variance in publicity measures, or perhaps by an individual’s belief that he or she may gain a competitive advantage by checking the “right” box on the application form. Additionally, it must be noted that students who ultimately matriculate into PRIME-HEq receive a small annual stipend to offset the costs of the master’s degree year. Although this may serve as a small incentive to some students, our sense is that it is not a large-enough incentive to account for the results of our study. Currently, the majority of PRIME-HEq recruitment is student driven. Because many of our students are involved in the Latino Medical Student Association and Student National Medical Association, PRIME has been showcased by these organizations. The current recruitment strategy does not diminish the findings of this study, however, as the results may imply successful recruitment efforts.
Still, the greatest implication of our study is that URM and disadvantaged students may be more likely to seek a program that delays graduation and requires additional education if the program is related to a familiar community. We presume that the extent to which a student feels connected to the program’s mission on a personal level is the greatest attraction. By simply adopting the priority to focus more on health care disparities—if only for a selective cohort—UC has found one way to address a call for diversity.
Acknowledgments: The authors thank Jesse Brennan, MA, Rema Raman, PhD, and David C. Chang, MPH, MBA, PhD, for their technical and statistical advice. They also thank Carolyn Kelly, MD, for review of the study proposal and Brian Zeglen for assistance with data collection.
Funding/Support: This study was partially supported by grant number D34HP18954, from the University of California, San Diego, Hispanic Center of Excellence, Health Resources and Services Administration.
Other disclosures: None.
Ethical approval: This study was found exempt from IRB approval by the University of California, San Diego, human research protections program.
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