Something big is brewing in Texas -- a new medical school that aims to change the way medical students in the state are recruited and trained, and that ultimately will steer many of them straight into a career in primary care.
Stephen Spann, M.D., M.B.A., founding dean of the University of Houston College of Medicine, has been a family physician for nearly four decades and has gained much experience in many areas, including medical education and global health issues. He says his current position "represents my career's work of learning and thinking about the kind of doctors we need to train."
Plans for the University of Houston (UH) College of Medicine were first discussed in 2013, and a vision for its framework began to take shape in 2014.
Along the way, those charged with crafting the medical school's focus and curriculum proclaimed a bold goal: 50 percent of graduates will pursue primary care in family medicine, internal medicine or pediatric residency programs.
But administrators didn't stop there; they also vowed to achieve, over time, a demographic mix whereby 50 percent of their student body will identify as an underrepresented minority.
Pending accreditation by the Liaison Committee on Medical Education, the inaugural class of 30 medical students will begin their studies in 2020 -- tuition free -- thanks to an anonymous $3 million donation.
That's the short version of this story. But the enticing details are best told by Stephen Spann, M.D., M.B.A., vice president of medical affairs and founding dean of the UH College of Medicine.
Spann, who's been involved in family medicine education for 39 years, spent some time with AAFP News answering a variety of questions about a venture that, in his words, "has been a gradual process, but from the very beginning, senior leadership at the university, and then the faculty, were intrigued with this mission and have really bought into it."
Of course, the promise of $100,000 to fund each student in the first class is a great kickoff.
"We think the scholarships will do two things. First, they will help us attract great medical students. Secondly, the decreased debt load may reduce the temptation for students to bypass primary care and choose higher-paying procedural specialties," said Spann.
He noted the importance of developing additional scholarship and loan repayment programs to keep similar financial incentives front and center for future classes as well.
Want to know more? Read on.
Q. Why does Texas need more primary care physicians?
A. We are ranked 47th out of 50 states in terms of our primary care physician-to-population ratio, and if we wanted just to reach the national average, we'd need about 4,600 additional primary care physicians in Texas today. The country has a deficit -- and we in Texas have a significant deficit -- of primary care physicians.
We have shortages in both rural and urban areas of our state. There are significant numbers of health professional shortage areas and primary care underserved areas even in the greater Houston area, so we want some of our graduates to practice in those underserved areas.
Q. What is your recruiting strategy for the inaugural class and beyond?
A. Two things. We plan to use a holistic admissions process that will pay attention to factors beyond GPA and the MCAT (Medical College Admission Test). There's pretty good data that shows those are not terribly predictive of the quality of physician you're going to produce, and they probably tend to bias your admission toward folks more likely to choose non-primary care specialties. Other factors have been identified that predict primary care specialty choice, so we'll pay a lot of attention to those.
In terms of trying to get more underrepresented minorities, we hope to develop some pipeline programs that reach into high school, middle school, maybe even elementary school to get young people from those underrepresented minorities interested in a medical career. The University of Houston is the second most diverse public university campus in the nation, so we have a have a good pipeline from our own premedical programs.
We would like our medical student population to reflect the population of Texas, which is 40 percent Hispanic, 12 percent African-American.
Q. What is your strategy for keeping your graduates in the state for residency and beyond.
A. I've been in family medicine education in this state for 28 years now -- I know the residency programs and most of the program directors across the state, and I work closely with our state Academy (Texas AFP).
We will certainly encourage our graduates to pursue residency education in the state, because we know that in Texas, if you do your medical school and residency in the state of Texas, you have an 80 percent probability of practicing in Texas. And if you're a family medicine resident, the probability soars to 90 percent or more.
We want our students to train at the residencies in this state so they will stay and take care of the population of this state.
Q. How soon can you realistically expect that half of your graduates will pick primary care?
A. I'd like to meet that goal with our first graduating class. When people ask how we're going to achieve that level, I talk about the intake process and the students we'll admit, and I tell them about a curriculum that is going to be very strong in primary care.
I also mention the culture we're developing -- and part of that culture is dependent on the faculty. We're recruiting professionals who have a real affinity for primary care, and a significant number of our faculty will be primary care physicians. We will, of course, also depend on subspecialists to help train our students.
With that said, it is not going to be OK for any faculty member to ever tell a student, "You are too smart to be a primary care doctor."
Q. What will your curriculum look like?
A. We're building in a lot of exposure to primary care, continuity of care, family-oriented care. And then through those experiences, students will learn a lot about social determinants of health and start to understand health disparities.
Every student will spend one half day a week, every week for four years of medical school, in a primary care setting. We're calling that the longitudinal primary care clerkship.
One week a month, those students will be part of an interprofessional student team that includes the medical student, a nursing student, a pharma student, a social work student, perhaps a law student and others. The team will be assigned to a family with complex medical and social problems and who lives in an underserved community. The teams will take care of those families, and will visit them monthly to provide education and advocacy. This may not entail hands-on care, but the health care teams will partner with patients to help them navigate the health care system.
The curriculum also features a core clerkship year with 24 weeks spent in a longitudinal integrated clerkship that includes outpatient experiences with preceptors in family medicine, internal medicine, pediatrics, surgery, OB/Gyn, neurology and psychiatry.
And every student will do a four-week rural health rotation -- likely in a primary care specialty.
Q. What has been the response from the medical community in Texas and from around the country?
A. People recognize and write about the importance of having a curriculum that teaches about social determinants of health and health disparities, a curriculum that teaches about how to improve the value of heath care. A lot of the important elements of our curriculum are addressing what the experts say we need to do in terms of training the next generation of physicians. That's been received very positively.
Q. Can you explain the underlying reasons why the United States continues to struggle with building an adequate primary care workforce?
A. Graduates may be tempted to vote with their wallets, and most experts believe that discrepancies in pay plays a role in specialty choice, but I don't think that's the only thing.
There are other issues, including modern students' interest in work/life balance; for some reason, students have gotten the idea that modern primary care doesn't offer that balance, when in fact it does.
Also, some medical students are enamored with technology and want to use a lot of it in their practices. Primary care physicians use technology, too, but ours is much more a relational specialty than a technological specialty.
The other reality is that most of our traditional medical schools harbor a hidden curriculum that discourages students from going into primary care. I can't count how many times I've had students tell me they came to medical school thinking about becoming a primary care doctor, but Professor X -- insert any "ologist" -- told them they were too smart to be a primary care doctor.
Those professors are not being malicious or malevolent, but traditional medical school faculty, especially subspecialists who've spent their entire careers in academic medicine, really don't understand primary care.
They don't understand that being a great primary care physician is the ultimate intellectual challenge in medicine.
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