Mission-driven Physicians More Likely to Practice Among Urban Underserved, Study Finds

Medical Schools Can Target Such Applicants for Admission, Says FP Investigator

November 10, 2010 04:50 pm Barbara Bein

Physicians with mission-based values (i.e., a sense of responsibility or moral obligation to a particular community or a defined patient population) as well as those who self-identify with a certain community and its patient population, are more likely to practice in urban underserved areas. Recognizing this, medical schools interested in identifying physicians motivated to practice in underserved areas can examine such humanistic- and intrinsic-level factors in greater detail to identify and recruit mission-driven students.

Moreover, clinical practices in physician-shortage areas can retain these mission-driven physicians through modifications in work hours and other lifestyle factors.

These are among the findings of a study led by family physician Kara Odom Walker, M.D., M.P.H., M.S.H.S., that involved primary care physicians in Los Angeles County. The study, "Recruiting and Retaining Primary Care Physicians in Urban Underserved Communities: The Importance of Having a Mission to Serve(ajph.aphapublications.org)," was published in the November American Journal of Public Health.

"Many studies have shown that those from underserved, rural and minority backgrounds are more likely to return and remain in underserved areas," Walker said in an interview with AAFP News Now. "We need to continue to encourage students throughout the pipeline to consider opportunities in underserved communities.

"We need to identify motivated and mission-driven premedical students prior to entering medical school and support their interests through training and mentorship opportunities in medical school."

Researchers Identify Mission-based Values as Key Factor

Study researchers conducted in-depth interviews with 42 physicians, including African-American, Latino and non-Latino white individuals, who practiced in underserved and nonunderserved areas of Los Angeles County. Most of those interviewed practiced internal medicine (48 percent), followed by family medicine (31 percent) and pediatrics (17 percent). The remainder identified themselves as practicing in some other primary care field.

Researchers examined the physicians' childhood backgrounds, residency training locations and practice locations to date, starting their queries with the basic question, "How did you decide to work here?" They then segmented responses into three domains of factors that affected the physicians' current choice of practice location: personal motivators, career motivators and clinic support.

Personal motivators included opportunities for personal growth; self-identity, as influenced by language and personal, family, cultural, socioeconomic or geographic backgrounds; and mission-based values, such as a sense of responsibility to a particular community or patient population.

According to the study, physicians who worked in underserved areas were more likely to emphasize mission-based values and self-identity as reasons for choosing their practice location.

Medical School Enrollment for 2010 Shows Gains in Diversity

The number of underrepresented minorities -- including Hispanics, blacks/African Americans and Native Americans -- among first-year U.S. medical students increased in 2010, according to the Association of American Medical Colleges, or AAMC.

In a recent press release(www.aamc.org), the AAMC said the biggest gains in medical school enrollment were among Hispanics, whose total enrollment this year rose 9 percent compared with that for 2009. The number of Hispanic males enrolled in the nation's medical schools increased by more than 17 percent.

Although the number of Native Americans who attend medical school remains small, the number of 2010 enrollees grew by almost 25 percent compared with last year's figures; enrollment of blacks/African Americans grew by almost 3 percent, the AAMC said.

"Improving the diversity of U.S. medical students will be a driver of excellence in our health care system," said AAMC President and CEO Darrell Kirch, M.D., in the press release. "We are very encouraged that more minority students are pursuing a career in medicine and hope that these strong gains continue in the years ahead."

Additionally, researchers found that more than 80 percent of physicians who trained in or who were from an underserved area worked in an underserved setting; no physicians who trained in a nonunderserved setting went to work with the underserved.

Indeed, the study reported, physicians gave ringing personal endorsements for deciding to practice in urban underserved communities. One told the researchers, "I grew up in the East Los Angeles community…I grew up uninsured…so that was a big motivation to come back and practice in the community here."

Another said, "I feel like I have a moral obligation to be here."

"Regardless of their race and ethnicity, the majority of physicians who practiced in underserved areas reported feeling a unique connection to the particular community in which they practiced," the study said.

Recruit Mission-focused Applicants to Help Ease Access Problems

Walker herself fits the profile of physicians who work with the underserved. An African-American physician, she told AAFP News Now that she became interested in the urban underserved because of personal experiences that reminded her of the importance of mission-driven work.

Walker said she sought opportunities to train in a supportive medical school, eventually choosing Jefferson Medical College in Philadelphia where she followed an urban underserved track. She completed her residency at the University of California-San Francisco General Hospital Family and Community Medicine Residency Program, which she described as being in an urban underserved environment with a diverse patient population.

According to Walker, medical schools should consider moving from a reliance on score-based criteria for admission to a focus on identifying mission-focused applicants as part of efforts to boost the number of physicians who practice among the underserved.

"Medical schools can work to find successful strategies (to identify such applicants) through reviewing the candidate's background, including their family background, experiences and setting," she said. "The application process should also include information about what types of experiences they had in underserved settings growing up and throughout their educational experiences."

Although medical students with a sense of mission are more likely to practice among the underserved, said the study, retaining physicians in these communities frequently involves work-life balance factors.

The few physicians who told researchers they left, or considered leaving, practice in underserved communities said they did so because of work hours and lifestyle issues.

"Work's effect on time spent with family, pursuing hobbies and making other lifestyle choices was described as an important reason for choosing a practice location by the majority of physicians," Walker said.

"Clinics can provide flexible work options, shorter work hours or more clinic support to decrease on-call hours," she added. "Many physicians in underserved areas considered leaving positions to find opportunities that are more flexible and accommodating."

Employing these recruitment and retention strategies will likely go a long way toward developing a corps of motivated, mission-driven and committed primary care physicians who can help reduce the disparities in health care among the underserved, the study said.