The results of our study show that participation in the Bloomer Hill Rural Health Course is associated with choosing to practice in primary care after residency. Although the relationship between Bloomer Hill involvement during medical school and future work with underserved populations, or in rural settings cannot be understood by our small study, continued monitoring for these outcomes may reveal an association. Continued evaluation of the Bloomer Hill Rural Health Course and of other curricular experiences, paying particular attention to long-term career decisions, may help strengthen the evidence behind such interventions and allow for better understanding which aspects of curricular interventions are most important and influential.
38
Providing opportunities for longitudinal service-learning experiences in primary care settings should be considered among other interventions for building the primary care workforce from within medical education.
39
References
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3. Hauer KKE. Factors associated with medical students' career choices regarding internal medicine. JAMA : the journal of the American Medical Association. 2008;300(10):1154-1164. 4. Pugno PA. Results of the 2009 national resident matching program: Family medicine. Fam Med. 2009;41(8):567.
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8. Bennett KKL. Finding, recruiting, and sustaining the future primary care physician workforce: A new theoretical model of specialty choice process. Academic medicine. 2010;85(10):S81-S88. 9. Meurer LN. Influence of medical school curriculum on primary care specialty choice:
Analysis and synthesis of the literature. Acad Med. 1995;70(5):388-397.
10. Barrett FA, Lipsky MS, Nawal Lutfiyya M. The impact of rural training experiences on medical students: A critical review. Acad Med. 2010.
11. Rabinowitz HK, Diamond JJ, Markham FW, Santana AJ. Increasing the supply of rural family physicians: Recent outcomes from jefferson medical college's physician shortage area program (PSAP). Acad Med. 2010.
12. Halaas GW, Zink T, Finstad D, Bolin K, Center B. Recruitment and retention of rural physicians: Outcomes from the rural physician associate program of minnesota. J Rural Health. 2008;24(4):345-352.
13. Kubal VS, Zweifler J, Hughes S, Reilly JM, Newman S. The relationship between a statewide preceptorship program and family medicine residency selection. J Am Board Fam Med. 2010;23(1):67-74.
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14. Glasser MM. A comprehensive medical education program response to rural primary care needs. Academic medicine. 2008;83(10):952-961.
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2006;296(20):2467-2475.
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19. Owen JA, Hayden GF, Connors Jr AF. Can medical school admission committee members predict which applicants will choose primary care careers? Academic Medicine. 2002;77(4):344. 20. Lynch DC, Teplin SE, Willis SE, et al. Interim evaluation of the rural health scholars
program. Teach Learn Med. 2001;13(1):36-42.
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Tables
Table 1: Characteristics of Study Sample (n=81) Total Sample (n=81) Bloomer Hill Participants (n=13) SHAC Leaders (n=13) Controls (n=55) P-Value Age, mean (SD) 28.4 (3.7) 28.2 (1.6) 27.1 (1.2) 28.7 (4.4) 0.35 Female Sex, % 56 69 77 47 0.09 Intended Primary Care at Matriculation, % 27 31 15 29 0.58 Race, % Black or African American White Other 10 67 23 15 69 15 15 62 23 7 67 25 .79
Table 1: Age is described as a continuous variable and compared using a oneway analysis of variance. Pearson chi-
square (χ2) tests were used to compare differences among categorical variables among each of the three cohorts
Table 2: Primary and Secondary Outcomes, by Cohort
Outcome Total Sample (n=81) Bloomer Hill Participants (n=13) SHAC Leaders (n=13) Controls (n=55) P-Value*
Primary Care Career (%) 25 46 15 22 0.13
Practice Setting Rural (%) Urban (%) Suburban (%) 12 53 35 15 54 31 8 38 54 13 56 31 0.62 Practice Population Underserved (%) 26 23 15 29 0.57 Level of Community Engagement Low (%) Medium (%) High (%) 32 41 27 46 23 31 46 39 15 25.5 45.5 29 0.35 ≥8 hours/week providing uncompensated care (%) 23 15 15 27 0.50
42 Table 3: Relative Odds of Primary and Secondary Outcomes*
Outcome
SHAC Leaders Bloomer Hill Participants Relative
Odds
95% CI P-value Relative Odds
95% CI P-value
Primary Care Career** 0.79 (0.13, 4.9) p=0.8 5.5 (1.02, 29.1) p=0.047
Rural Practice Setting 0.57 (0.06, 5.1) p=0.6 1.25 (0.23, 6.8) p=0.8
Practice Population Underserved 0.44 (0.09, 2.2) p=0.3 0.73 (0.18, 3.0) p=0.7 High Level of Community Engagement 0.44 (0.09, 2.2) p=0.3 1.1 (0.3,4.0) p=0.9 ≥8 hours/week providing uncompensated care 0.48 (0.1, 2.4) p=0.4 0.48 (0.1, 2.4) p=0.4
*Odds ratios are compared to the control cohort.
**Adjusted for: sex, race, age at graduation, and intention to pursue primary care career at medical school matriculation
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Appendix A: Quantitative Data Collection Materials
Electronic Survey: Specialty Choice:
What type of residency program did you complete?
Family Medicine General Surgery Ophthalmology
Internal Medicine OB/GYN Anesthesiology
Pediatrics Radiology ENT
Dermatology Radiation Oncology Other:
What type of fellowship training have you completed, or are you currently completing? I have not received fellowship training
Internal Medicine sub-specialty Pediatric sub-specialty
Surgical sub-specialty OB/GYN sub-specialty Other:
Did you intend to go into primary care when you first entered medical school? Yes
No
I was considering it.
Practice Setting:
Are you currently in residency or in fellowship training? Residency
Fellowship Neither
How would you describe the setting in which you practice, primarily? Public hospital
Private hospital
Private outpatient setting
Community Health Center/FQHC
Not currently practicing clinical medicine Other:
How would you describe the geographic location? Rural
Urban Suburban
Do you work in a Health Provider Shortage Area (HPSA, population to primary care provider ratio ≥3,500:1) or a federally designated Medically Underserved Area/Population (MUA/MUP)?
44 No
I do not know
Approximately what proportion of your patients are Medicaid patients or uninsured? 0%-30%
30% to 70% >70%
Approximately what proportion of your patients are Medicare patients? 0%-30%
30% to 70% >70%
Community Engagement:
Approximately how many hours per week do you spend providing uncompensated care? None
1-3 4-8 >8
How important is it for physicians to provide health-related expertise to local community organizations (eg, school boards, parent-teacher organizations, athletic teams, and local media)?
Not at all important Not very important Somewhat important Very important
In the past 2 years have you provided health-related expertise to local community organizations? Yes
No
How important is it for physicians to be politically involved (other than voting) in health-related matters at the local, state, or national level?
Not at all important Not very important Somewhat important Very important
In the past 2 years have you been politically active (other than voting) on a local health care issue? Yes
No
How important is it for physicians to encourage medical organizations to advocate for the public’s health? Not at all important
Not very important Somewhat important Very important
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In the past 2 years, have you encouraged your professional society to address a public health or policy issue that is not primarily concerned with physician welfare?
Yes No
Demographic Information:
Graduation Year:
What additional degrees did you earn during medical school? MPH PhD MBA Gender: Male Female Race:
Black or African American American Indian or Alaska Native Asian
Native Hawaiian or Other Pacific Islander White
Hispanic or Latino Other
Prefer not to disclose Birth year:
Did you participate in the Bloomer Hill Course while you were in medical school at UNC? Yes
No
Did you hold a leadership position in the Student Health Action Coalition (SHAC)? Yes
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Appendix B: Qualitative Data Collection Materials
Key Informant Interview Guide:
1. Tell me about your experience with the Bloomer Hill clinic during medical school?
a. Which years of your medical school training were you involved with the Bloomer Hill Clinic? b. What was the most meaningful part of the experience for you?
2. How did your experience with the clinic influence your specialty choice?
a. What type of specialty were you interested in pursuing when you entered medical school? If this is different from what you ultimately chose, how did the Bloomer Hill course influence your decision?
b. What aspects of the program were influential in this decision (ex. the clinic itself, the preceptors or mentors you encountered, the continuity of care with patients, specific class components or assignments)?
3. How did your experience with the clinic influence the type of setting and population with which you’ve decided to practice or intend to practice?
a. What aspects of the program were influential in this decision (ex. the clinic itself, the preceptors or mentors you encountered, the continuity of care with patients, specific class components or assignments)?
4. How did your experience with the clinic influence the way in which you are engaged in your community (eg. volunteering your services, participating in political legislation)?
a. What aspects of the program influenced this decision (ex. the clinic itself, the preceptors or mentors you encountered, the continuity of care with patients, specific class components or assignments)?
5. What other aspects of medical school (ex. co-curricular or extracurricular experiences, mentors) influenced your specialty choice, your practice setting, and the way you are engaged in your community?
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Acknowledgments
I would like to thank my adviser, Dr. Amy Denham, for her encouragement, creativity, and intellectual support through this project. This work would not have been possible without her guidance, experience, and eye for detail.
I thank Dr. Anthony Viera, my second reader, for his enthusiasm and frequent feedback on this work. His knowledge and experience in advising research projects was instrumental in the implementation of this project and production of this final product.
I am grateful for the opportunity to learn from these two excellent teachers and family physicians, who both show great dedication to primary care and to student development.
Finally, I would like to acknowledge the inspiring commitment to service demonstrated by all of the past and current Bloomer Hill People’s Clinic volunteers, leaders, and preceptors. These individuals have invested their time and energy into making the clinic a high quality place for patients to receive medical care and for students to learn about medicine, beyond the walls of a traditional classroom.