Thursday, Dec. 5, 2019
Ben Del Buono never planned on a career in medicine. He earned his undergraduate degree in 2009 and wanted to enter the nonprofit world, following his passion for social justice. However, his life changed a few years later when he got a job in a hospital as a patient transporter.
Del Buono, now a fourth-year medical student at the Virginia Commonwealth University School of Medicine, is among a group of medical students at VCU who have decided to work with underserved populations during medical school, allowing him to mix his interest in social justice with his medical education. The International/Inner City/Rural Preceptorship program is a four-year track for medical students that gives them additional training with underserved and vulnerable populations.
“I wanted to get into medicine, because I knew I could reach underserved populations,” Del Buono said. “I chose I2CRP as a way to continue that passion, and a way to compel me into residency.”
A shared perspective
The preceptorship program’s underpinnings are in public health, but its main goal is to enhance medical students’ interest in serving vulnerable populations as a general practice doctor.
“It is not a formal public health program, but there is a lot of overlap with public health ideas,” said Mark Ryan, M.D., an associate professor in the School of Medicine and the program’s medical director. “The broad statement of what I think I2CRP is trying to do is to provide medical students with the knowledge, skills and attitude to provide high-quality, culturally humble care to communities and individuals that might otherwise be left out of the health care system.”
Students learn about the barriers to health care that are system based as well as the social determinants that affect health care outcomes. They only apply for the program once they have started their medical education, but many of them know about it before entering medical school. Del Buono said the program is one reason he decided to attend medical school at VCU.
“I knew about it before I went,” he said. “It’s one of the perks of VCU.”
About half of the students who apply are accepted. Ryan said he and the other faculty members look for students who have a history of service and want to bring that into their medical education. They also are seeking students who are able to balance the extra workload that is required beyond a traditional medical education. The program is not easy and requires a commitment.
“We want to make sure people who join the program have a shared perspective about what this kind of work looks like,” Ryan said.
Get students into community settings
To begin the program, students meet in small groups and talk about their real-life experiences. The goal is to create bonds and help foster the shared passions and interests of the students prior to starting clinical rotations. The school wants to make sure the students have the tools necessary to be successful when serving vulnerable populations.
“People have lots of different backgrounds and how it comes forward is going to depend on the individual student’s experience and where they connect within the work that we do,” Ryan said.
While in the program, third-year medical students are required to do some of their rotations outside the hospital and in the community. Mary Lee Magee, International/ Inner City/Rural Preceptorship director, said the program is designed to give medical students unique experiences and link them with mentors who carved out a career serving vulnerable populations. That is best accomplished in a range of settings.
Students can work anywhere from a homeless shelter to a clinic that caters to immigrant populations. International opportunities are also available. Bethany Howlett, M.D., graduated from the program and now works in the School of Medicine and Public Health at the University of Wisconsin. She chose to do one of her clinical rotations in the Dominican Republic, and said the experience was an extremely important part of her medical training.
Del Buono said his rotation at an opioid addiction clinic in Roanoke, Virginia, was a life-changing experience. He saw how the opioid crisis was ravaging the community and the challenges of treating addiction within a vulnerable population.
“It was heavy,” Del Buono said. “You had people who were there who were still getting high but wanted to get clean and you had people who were already clean and wanted to stay clean.”
Magee said the experiences that Del Buono and Howlett had during their clinical rotations were very different from those of most medical students. The students dealt with complex medical problems but also had to confront multifaceted social issues such as housing instability, limited access to jobs or education, and structural obstacles accessing adequate health care.
“We know that what happens in the exam room addresses only 20% of overall health outcomes. We need to help students look at the health of individuals and communities with a broader lens.” Magee said.
Promoting VCU’s approach
Magee, Ryan and Yeri Park, M.D., a 2017 School of Medicine graduate, recently sought to highlight the VCU program and its effectiveness to a national audience. While similar programs exist within medical schools across the country, no national curriculum has been developed. The group wanted to promote VCU’s approach, and that effort led to publication of an article in the journal Family Medicine.
The article, Ryan said, emphasized the program’s success at drawing people into a primary care practice. Around 85% of students who complete the program enter a workforce priority area, which includes primary care such as family medicine, internal medicine, or pediatrics, but also psychiatry, general surgery or ObGYN. Ryan said that while the program may not drive people to enter primary care, it fosters a natural inclination that already exists within the students to address healthcare needs.
“The program brings out the student’s intrinsic motivation to do this work and sustains that interest and motivation,” Ryan said.
Howlett agrees. She already had an interest in working with underserved populations within a primary care practice, but the program fostered it and drew it out of her. She was able to take her interests and background and hone them into a practice.
“It was an interest of mine prior to medical school, but I was not sure how I would integrate it,” Howlett said, adding, “People in the program have innovative approaches to accessing health care.”
Magee said publication of the article is a significant step and allows VCU to participate in a larger conversation nationally on the best ways to address workforce shortages and increase the number of medical students who choose careers in primary care and practice in medically underserved areas. The curriculum, she said, has evolved significantly, and she believes VCU has developed a model that works.
“Hopefully we will continue to communicate with our colleagues nationally,” Magee said. “I think there is a lot to learn from others in developing the program.”
We know that what happens in the exam room addresses only 20% of overall health outcomes. We need to help students look at the health of individuals and communities with a broader lens.
Support of the administration
The roots of the preceptorship program can be traced to a federal government grant through the Health Resources and Services Administration in the late 1990s. The agency provides programs to improve “health care to people who are geographically isolated, economically or medically vulnerable,” according to its website. The grant allowed for creation of a program that educated students about providing medical care in rural and inner city areas.
In 2009, the VCU School of Medicine received a second Health Resources and Services Administration grant, which allowed for the program’s expansion into international care, and the number of students was increased. The program now can accept 24 students each year.
The program requires sustained support of the university. It is more expensive to train doctors through the program than a traditional medical education. VCU pays the facilities that accept students an honorarium, and it also must provide housing at some of the facilities outside the Richmond area.
“My sense is the School of Medicine leadership sees the value in this program and supports the mission of the program,” Ryan said.
Howlett said the program is worth the extra cost, even if a student does not work directly with underserved populations. The program teaches valuable skills that can be used within any practice of medicine. It teaches doctors to consider the larger context of the patient’s life outside the clinical setting.
“These are skill sets that everyone going into medicine needs,” Howlett said. “The skills you build through I2CRP will only help. It’s like a Swiss Army knife. It’s a multifunctional tool in the toolkit.”
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