Care For Underserved Research Articles

Preparing behavioral health clinicians for success and retention in rural safety net practices.

This study assesses how, among behavioral health clinicians working in rural safety net practices, the amount of exposure to care in rural underserved communities received during training relates to confidence in skills important in their work settings, successes in jobs and communities, and anticipated retention. This study uses survey data from Licensed Clinical Social Workers, Licensed Professional Counselors, and Psychologists working in rural safety net practices in 21 states while receiving educational loan repayment support from the National Health Service Corps, from 2015 to April 2022. Of the 778 survey respondents working in rural counties, 486 (62.5%) reported they had formal education experiences with medically underserved populations during their professional training, for a median of 47 weeks. In analyses adjusting for potential confounders, the estimated amount of rural training exposure was positively associated with a variety of indicators of clinicians' integration and fit with their communities as well as with longer anticipated retention within their rural safety net practices. The amount of training in care for rural underserved populations was not associated with clinicians' confidence levels in various professional skills or successes in their work, including connection with patients and work satisfaction. Formal training in care for underserved populations is a large part of the education of behavioral health clinicians who later work in rural safety net practices. More training in rural underserved care for these clinicians is associated with greater integration and fit in their communities and longer anticipated retention in their practices, but not with skills confidence or practice outcomes.

Assessing perspectives of a global health area of concentration within the PharmD curriculum

IntroductionWhile global health education in pharmacy expands, limited research has described the outcome of completing a global health area of concentration on career decisions, perceptions on cultural sensitivity, health disparity awareness, and global health competencies among pharmacists and students. MethodsThis mixed methods study enrolled 21 graduates and 17 student pharmacists who participated in a global health concentration at one school of pharmacy in the United States. Data sources included graduate interviews and surveys, student pharmacist focus groups, and global health competency self-assessments. ResultsFive themes emerged among graduates: (1) skills were applicable to diverse settings, (2) early exposure to underserved care prepared graduates for current practice, (3) participation impacted the lens through which graduates viewed careers, (4) participation influenced patient care in current practice, and (5) graduates gained insight on complex global health issues. Three themes were identified among student pharmacists: (1) the program provided opportunities to personalize education, (2) participants gained insight through hands-on experience, and (3) participants developed new perspectives on approaching underserved care. Many graduates (77.4%) currently practiced in an underserved setting. Graduates and fourth professional year students reported improvement in all seven global health competency domains. ConclusionsA global health concentration in pharmacy curricula can facilitate skills and global health competencies that are applicable across a wide variety of patient care contexts. This concentrated experience provided opportunities to further develop career interests and personalize education, creating a cadre of pharmacists dedicated towards addressing health disparities and serving the underserved.

Preliminary Workforce Outcomes of an Urban Longitudinal Integrated Clerkship.

The authors examined whether students participating in an urban longitudinal integrated clerkship (LIC) with a curriculum focused on care for underserved populations have a sustained commitment to urban underserved care through residency training and into practice. This mixed-methods study collected data from medical student application essays to the Denver Health LIC (DH-LIC), end-of-course surveys, residency match outcomes, and postgraduation surveys annually for academic years 2014 to 2022. The authors analyzed students' responses to the surveys on interest in working with underserved patients, understanding the rewards and challenges of working in safety net institutions, working in the community to improve health, and working at DH. The authors qualitatively coded the 70 application essays of all selected students using summative content analysis. Seventy DH-LIC students were compared with 1,450 medical students between 2014 and 2022. Qualitative analysis of LIC application essays revealed 3 themes: interest in working with underserved populations, work experience with underserved populations, and personal experience with medical vulnerability. Fifty-seven DH-LIC participants (81.4%) expressed high levels of career interest in working with underserved populations, 45 (64.3%) had high levels of work experience with underserved populations, and 18 (25.7%) expressed high levels of personal experience. Graduates of the DH-LIC program demonstrated a high degree of continuing interest in practicing in urban underserved settings throughout medical school and postgraduate training. Ten graduates (71.4%) in practice work in urban underserved settings. Participants reported a high or very high level of interest and commitment to working with underserved populations (96.7%-100%), understanding the safety net health care system (91.7%-98.6%), and working in communities (95.0%-100%) at all time points studied. Early data indicate high rates of graduates working in urban underserved settings. These preliminary outcomes suggest the LIC may support the development of a committed workforce for urban underserved communities.

Health Disparity Curricula for Ophthalmology Residents: Current Landscape, Barriers, and Needs.

Background Social determinants of health play a critical role in visual health outcomes. Yet, there exists no structured curriculum for ophthalmology residents to identify and address health disparities relevant to eye care or no a standard assessment of health disparities education within ophthalmology residency programs. This study aims to characterize current health disparity curricula in ophthalmology residency programs in the United States, determine resident confidence in addressing health disparities in the clinical setting, and identify perceived barriers and needs of program directors (PDs) and residents in this area. Design This was a cross-sectional survey study. Methods A closed-ended questionnaire with comments was distributed to the Accreditation Council for Graduate Medical Education-accredited ophthalmology residency PDs and residents in April 2021 and May 2022. The questionnaire solicited characteristics of any existing health disparity curricula, PD and resident perceptions of these curricula, and residents' experience with and confidence in addressing health disparities in the delivery of patient care. Results In total, 29 PDs and 96 residents responded. Sixty-six percent of PDs stated their program had a formal curriculum compared to fifty-three percent of residents. Forty-one percent of PDs and forty-one percent of residents stated their program places residents in underserved care settings for more than 50% of their training. Most residents (72%) were confident in recognizing health disparities. Sixty-six percent were confident in managing care in the face of disparities and fifty-nine percent felt they know how to utilize available resources. Residents were most concerned with the lack of access to resources to help patients. Forty-five percent of PDs felt the amount of time dedicated to health disparities education was adequate. Forty-nine percent of residents reported they felt the amount of training they received on health disparities to be adequate. The top barrier to curriculum development identified by PDs was the availability of trained faculty to teach. Time in the curriculum was a major barrier identified by residents. Conclusions Roughly half of ophthalmology residency programs who responded had a health disparity curriculum; however, both PDs and residents felt inadequate time is dedicated to such education. National guidance on structured health disparity curricula for ophthalmology residents may be warranted as a next step.

Diversity and Career Goals of Graduating Allopathic Medical Students Pursuing Careers in Dermatology

Dermatology is one of the least diverse specialties, while patients from minority racial and ethnic groups and other underserved populations continue to face numerous dermatology-specific health and health care access disparities in the US. To examine the demographic characteristics and intended career goals of graduating US allopathic medical students pursuing careers in dermatology compared with those pursuing other specialties and whether these differ by sex, race and ethnicity, and/or sexual orientation. This secondary analysis of a repeated cross-sectional study included 58 077 graduating allopathic medical students using data from the 2016 to 2019 Association of American Medical Colleges Graduation Questionnaires. The proportion of female students, students from racial and ethnic groups underrepresented in medicine (URM), and sexual minority (SM) students pursuing dermatology vs pursuing other specialties. The proportions and multivariable-adjusted odds of intended career goals between students pursuing dermatology and those pursuing other specialties and by sex, race and ethnicity, and sexual orientation among students pursuing dermatology. A total of 58 077 graduating students were included, with 28 489 (49.0%) female students, 8447 (14.5%) URM students, and 3641 (6.3%) SM students. Female students pursuing dermatology were less likely than female students pursuing other specialties to identify as URM (96 of 829 [11.6%] vs 4760 of 27 660 [17.2%]; P < .001) or SM (16 [1.9%] vs 1564 [5.7%]; P < .001). In multivariable-adjusted analyses, students pursuing dermatology compared with other specialties had decreased odds of intending to care for underserved populations (247 of 1350 [18.3%] vs 19 142 of 56 343 [34.0%]; adjusted odd ratio [aOR], 0.40; 95% CI, 0.35-0.47; P < .001), practice in underserved areas (172 [12.7%] vs 14 570 [25.9%]; aOR, 0.40; 95% CI, 0.34-0.47; P < .001), and practice public health (230 [17.0%] vs 17 028 [30.2%]; aOR, 0.44; 95% CI, 0.38-0.51; P < .001) but increased odds of pursuing research (874 [64.7%] vs 29 121 [51.7%]; aOR, 1.76; 95% CI, 1.57-1.97; P < .001) in their careers. Among students pursuing dermatology, female, URM, and SM identities were independently associated with increased odds of caring for underserved populations (eg, URM: aOR, 4.05; 95% CI, 2.83-5.80) and practicing public health (eg, SM: aOR, 2.55; 95% CI, 1.51-4.31). URM students compared with non-URM students pursuing dermatology had increased odds of intending to practice in underserved areas (aOR, 3.93; 95% CI, 2.66-5.80), and SM students compared with heterosexual students pursuing dermatology had increased odds of intending to become medical school faculty (aOR, 1.60; 95% CI, 1.01-2.57), to pursue administrative roles (aOR, 1.60; 95% CI, 1.01-2.59), and to conduct research (aOR, 1.73; 95% CI, 1.01-2.98). The findings of this cross-sectional study suggest that diversity gaps continue to exist in the dermatology workforce pipeline. Efforts are needed to increase racial and ethnic and sexual orientation diversity and interest in careers focused on underserved care and public health among students pursuing dermatology.

Letter Response: Design and Implementation of a Global Health and Underserved Care Track.

Letter Response: Design and Implementation of a Global Health and Underserved Care Track.

Letter: Design and Implementation of a Global Health and Underserved Care Track.

Letter: Design and Implementation of a Global Health and Underserved Care Track.

Design and Implementation of a Global Health and Underserved Care Track in an Otolaryngology Residency.

Despite widespread resident interest in global health and underserved care, few otolaryngology residency programs offer a formal global health experience. This article is the first to characterize a formal otolaryngology global health and underserved care track with a focus on how this curriculum integrates with and supplements resident education. Components of the track include longitudinal limited-resource field experiences in domestic and abroad settings, a related quality improvement project, and completion of a formalized global health educational curriculum. In addition to delivering humanitarian aid, residents in this track obtain a unique educational experience in all 6 core competencies of the Accreditation Council for Graduate Medical Education. Early barriers to implementation included identifying mentorship, securing funding, and managing busy resident schedules. In this work, we detail track components, schedule by track year, keys to implementation, and potential educational pitfalls.

Fully Integrated Readiness for Service Training (FIRST): An Accelerated Medical Training Program for Rural and Underserved North Carolina.

The U.S. primary care workforce remains inadequate to meet the health needs of the U.S. population. Effective programs are needed to provide workforce development for rural and other underserved areas. At the University of North Carolina (UNC) School of Medicine (SOM), between November 2014 and July 2015, the authors developed and implemented the Fully Integrated Readiness for Service Training (FIRST) Program, an accelerated curriculum focused on rural and underserved care that links 3 years of medical school with a conditional acceptance into UNC's 3-year family medicine residency, followed by 3 years of practice support post-graduation. Students are recruited to the FIRST Program during the fall of their first year of medical school. The FIRST Program promotes close faculty mentorship and familiarity with the health care system, includes a longitudinal quality improvement project with an assigned patient panel, includes early integration into the clinic, and fosters a close cohort of fellow students. As of March 2020, the FIRST Program had successfully recruited 5 classes of medical students, and 3 of those classes had matched into residency. In total, as of March 2020, 18 students had participated in the FIRST Program. The FIRST Program will be expanded to additional clinical sites across North Carolina and to specialties beyond family medicine, including pediatrics, general surgery, and psychiatry.

Bridging health disparities: a national survey of ambulatory care pharmacists in underserved areas.

Background:There is a shortage of primary care medical providers, particularly in rural communities and communities of racial and ethnic minority groups. Clinical pharmacists can help fill gaps in care among these vulnerable populations.Objective:To identify characteristics of ambulatory care pharmacists that pursue and maintain employment within underserved areas.Methods:An original survey was distributed nationwide to ambulatory care clinical pharmacists in underserved settings. Respondent characteristics were analyzed using descriptive statistics.Results:Of the 111 completed surveys, a majority of respondents were White, non-Hispanic, female, with English as their only spoken language. A majority of pharmacists completed a clinical experience or specialized training focused on underserved care prior to their position. The top three motivators for pharmacists accepting their clinical position as well as staying at their job were passion for caring for underserved populations, the presence of a faculty appointment, or the freedom and flexibility of advanced clinical roles.Conclusions:With a large majority of our respondents identifying as White and unilingual, there remains a large opportunity to increase diversity in the clinical pharmacy ambulatory care workforce caring for underserved populations. There is an observed correlation between early experiential or specialized training in underserved care and pharmacists pursuing employment in these areas. Thus, one potential long-term strategy to diversify and grow the ambulatory care clinical pharmacist workforce in underserved settings is for clinical practice sites to partner with colleges of pharmacy to recruit and maintain quality individuals who can meet the needs of diverse patient populations as well as expand student and resident training opportunities in underserved settings.

Personal impact of providing clinical pharmacy services to transgender patients in underserved communities

“I took the bullet out of my nightstand.” As a clinical pharmacist working in a federally qualified health center clinic, I did not imagine I would hear these words so early in my career. Being fresh out of residency, I thought I grasped the true impact of pharmacist services. However, after a few months on the job, an opportunity arose that changed my outlook on underserved care and the level of impact that pharmacists can make.

Student Interest in a Primary Care of Underserved Populations Course.

Medical students often lack curricular offerings specific to the care of underserved populations. We surveyed first- and second-year students to inform the development of a 4-week course on the skills necessary to care and advocate for underserved populations within a primary care context. This study assessed students' interest in the potential course, interest in primary care (PC) and underserved care (UC), and factors that would make the course more or less interesting to students. The authors designed and offered a survey examining UC, PC, and course interest to all first- and second-year students at one institution. Open-ended free-text survey responses were qualitatively analyzed using content analysis. Response rate was 72% (271/374). Most responding students (90%; 198/220) were very to somewhat interested in UC; 60% (132/220) were very to somewhat interested in PC; and 79% (173/220) were very to somewhat interested in the described course. Very interested students were more likely to endorse interest in learning about community advocacy, having a faculty mentor, clinical care experience, and loan repayment than those with low course interest (P&lt;.001). Analysis of open-ended responses revealed an emphasis on advocacy and career feasibility, resulting in the inclusion of these topics in the final course curriculum. This manuscript outlines potential areas of engagement for students demonstrating low or high interest in a Caring for Underserved Patients course. Our study may inform educators seeking to develop similar curricular interventions, particularly those who aim to recruit students to PC or UC careers.

A Longitudinal Underserved Community Curriculum for Family Medicine Residents.

Postgraduate education in cultural competence and community health is a key strategy for eliminating health disparities in underserved populations. Evidence suggests that an experiential, rather than knowledge-based approach equips physicians with practical and effective communication tools that generalize to a greater diversity of patients and cultures. However, there is limited data about the efficacy of a longitudinal, experiential residency curriculum. This study details the results of a longitudinal underserved community curriculum for family medicine residents training in a federally qualified health center. All residents in the first 5 years of a new residency participated in a longitudinal curriculum of workshops and seminars focused on social determinants of health and cultural competency for underserved patients. Pre- and postcurriculum surveys assessed knowledge gain. Self-reported Likert scale ratings assessed attitudes and confidence related to underserved care. Pre/post learning evaluations after each seminar documented average knowledge increase of 31.0% and 28.8%, respectively. At the end of the 3-year curriculum, 81.8% of residents reported confidence in their ability to incorporate culturally relevant information into a treatment plan and 57.1% of residents reported feeling very aware of obstacles faced by underserved populations seeking health care and of the relationship between sociocultural background, health, and medicine. A longitudinal, experiential curriculum in underserved community health and cultural competence can improve resident knowledge and attitudes with respect to health disparities and delivering health care to diverse patient populations.

Competencies required for general practitioners/family physicians in urban areas versus non-urban areas: a preliminary study

BackgroundThe medical practice of general practitioners/family physicians in urban areas differs from that in rural areas, accounting for the difference in specific competencies. However, variations in competencies in community healthcare required for general practitioners/family physicians in urban areas compared with those in rural areas have not yet been fully clarified. Thus, this study aimed to elucidate the competencies required for general practitioners/family physicians, especially in those characteristic to urban areas, and compare them with those in non-urban/rural areas.MethodsA qualitative study with individual interviews and qualitative data analysis was conducted. Participants were selected by purposive sampling, and 10 general practitioners/family physicians with clinical experience of ≥7 y after graduation and ≥ 1 y in both urban and non-urban (rural) areas in Japan were recruited. Additionally, semi-structured individual interviews in a private room around the workplace of the interviewee between September 2014 and September 2016 were conducted. For data collection, interview transcripts were analyzed according to the “Steps for Coding and Theorization” method, a sequential and thematic qualitative data analysis technique and data analysis since March 2018.ResultsWe interviewed 10 general practitioners/family physicians of Japan and extracted 10 themes as competencies characteristic to general practitioners/family physicians in urban areas. In addition to the known competencies on urban underserved care, we newly clarified the competencies of the ability to integrate divided care and ability to coordinate and collaborate with various medical care and welfare professionals in urban areas.ConclusionThis study was one of the few studies describing the characteristic competencies of urban general practitioners. In summary, a competency necessary for general practitioners in urban areas is to understand the urban context and provide contextual care suitable for urban areas. In the modern age, where urban population concentration is progressing and the interest in urban health is rising, our study will give certain suggestions for primary care education and practice necessary for urban areas.

Primary Care Residency Choice and Participation in an Extracurricular Longitudinal Medical School Program to Promote Practice With Medically Underserved Populations

In 2006, the University of Washington School of Medicine (UWSOM) launched the Underserved Pathway (UP), an extracurricular longitudinal experience supporting student interest in caring for underserved populations. This study examined the association between UP participation and residency choice. The study population was 663 UWSOM graduates who matched to a residency from 2008 to 2011; 69 were UP participants. Outcomes included matching to primary care residencies (family medicine, internal medicine, pediatrics, or medicine-pediatrics). The authors calculated graduate rates and odds of UP participants versus nonparticipants matching to primary care residencies overall and to residencies in individual primary care specialties. This analysis included all graduates and 513 graduates who had dual interest in primary care and underserved care at matriculation. Of 336 graduates matching to primary care, the authors calculated rates of entering the individual specialties with respect to UP participation. UP participants matched at significantly higher rates than nonparticipants to primary care (72.5% versus 48.1%, adjusted odds ratio [OR] 2.2) and family medicine residencies (33.3% versus 15.0%, adjusted OR 2.9). Of graduates with dual matriculation interest in primary care and underserved care, 73.4% of participants versus 53.5% of nonparticipants matched to primary care (adjusted OR 1.9), and 31.2% of participants versus 18.0% of nonparticipants matched to family medicine (adjusted OR 2.1). Of primary care matched graduates, 46.0% of participants versus 31.1% of nonparticipants entered family medicine. Supporting student interest in underserved careers is associated with higher rates of graduates entering primary care residencies, specifically family medicine.

Resident Education in Free Clinics: An Internal Medicine Continuity Clinic Experience

Most internal medicine (IM) residency programs provide ambulatory training in academic medical centers. Community-based ambulatory training has been suggested to improve ambulatory and primary care education. Free clinics offer another potential training setting, but there have been few reports about the experience of IM residents in free clinics. We assessed the feasibility and acceptability of inclusion of an ambulatory rotation in a free clinic and IM residency curriculum and the advantages of the free clinic setting over the traditional ambulatory clinic model. In 2010, the University of Chicago Internal Medicine Residency Program partnered with a free clinic in order to establish a community-based continuity clinic experience. To assess the feasibility of this innovation, 16 residents were surveyed 9months after implementation of the clinic to determine satisfaction, perceived preparation to address common medical conditions, and attitudes toward the underserved care population. A subset of these responses was compared to responses from residents in the traditional clinic model. Residents in the free clinic rotation were more satisfied and perceived they were more prepared to work in low-resource settings and reported similar levels of preparation regarding common outpatient conditions than residents in a traditional continuity clinic format. They reported increased future likelihood of working in an underserved clinic. Our exploratory study suggests free clinics may be an effective platform for community-based continuity clinic training.

Communities Committed to Underserved Care

Communities Committed to Underserved Care

University of Nebraska College of Medicine

University of Nebraska College of Medicine

Curriculum and Evaluation Results of a Third-Year Medical Student Longitudinal Pathway on Underserved Care

Background: There is a need to train compassionate and competent physicians to care for the growing underserved population in this country. Description : The authors developed the third-year Longitudinal Ambulatory Care Experience (LACE) Underserved Care pathway at Baylor College of Medicine in 2003 to help interested students prepare to be clinicians who care for the underserved. The pathway curriculum included seminar/journal clubs on relevant underserved care topics, clinical time with an underserved care preceptor, visits to community organizations, an assignment to help an uninsured patient obtain health care funding, and a group project. The authors report on the student evaluations of the first 4 years of the pathway, 2003 to 2007. The Institutional Review Board of Baylor College of Medicine granted this educational study exempt status. Evaluation : Students highly rated each pathway component in enhancing their knowledge, skills and attitudes. For 2005 to 2007, students rated most knowledge, skills, and attitudes items more highly at the conclusion of the pathway compared to the beginning ( p <.05). Conclusions : The pathway has been successful in enhancing knowledge, skills, and attitudes in underserved care for its participants. Further study is needed to evaluate long-term outcomes of participants in this pathway, including practice setting, knowledge, skills, attitudes, quality of care, and ability to help patients navigate through the health care system and overcome barriers.