Unique Premedical Education Experience in Public Health and Equity: Combined BA/MD Summer Practicum

doi:10.4236/ce.2013.47A2021

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Creative Education

2013. Vol.4, No.7A2, 165-170

Published Online July 2013 in SciRes (http://www.scirp.org/journal/ce) http://dx.doi.org/10.4236/ce.2013.47A2021

Unique Premedical Education Experience in Public Health and

Equity: Combined BA/MD Summer Practicum

Amy Clithero1, Robert Sapien2, Judith Kitzes3, Summers Kalishman1, Sharon Wayne4,

Brian Solan1, Lana Wagner1, Valerie Romero-Leggott1

1Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, USA

2Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, USA

3Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA

4Office of Program Evaluation, Education and Research, University of New Mexico School of Medicine,

Albuquerque, USA

Email: [email protected]

Received September 27th, 2012; revised November 1st, 2012; accepted November 18th, 2012

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the

original work is properly cited.

Background: Physicians will need increased skills in the areas of public health, equity based interventions

and patient safety skills to address the medical needs of patients in the 21st century. Premedical education

and experiences is one strategy to address these areas. Methods: A one month rural summer practicum

was developed for all BA/MD students. Key components include: 1) physician shadowing; 2) tutorials; 3)

narrative writings; and 4) group community projects. Students attend a preparatory community service

course prior to the practicum. Pre/post practicum surveys assessed students’ attitudes and skills with re-

spect to community interventions. Post practicum surveys evaluate the elements of the practicum. Results:

Survey results demonstrated no significant change in opinions or skills and activities with respect to

community interventions. Highly rated items in the post practicum evaluations included physician shad-

owing, community activities, and opportunities to learn from others. Conclusions: A pre-medical practi-

cum experience can help students define their roles as future physicians and increase their interactions

within communities around public health issues. Whether this translates into improved involvement of

physicians using public health equity based interventions is an area of ongoing study.

Keywords: Public Health; Pre-Medical Education; Health Equity; Service Learning; Combined BA/MD

Program

Introduction

The changing needs and expectations of society in preparing

physicians for the 21st century have resulted in several pub-

lished medical education reform papers. The central theme

cited in the majority of the reports is based on the Institute of

Medicine’s 2003 report, “Who Will Keep the Public Healthy?

Educating Public Health Professionals for the 21st Century”.

(IOM) Contemporary society is encouraging more focus on

public health, equity-based care delivery, and partnerships be-

tween Academic Health Centers (AHC) and the communities

they serve. These reports make recommendations including: 1)

the need to retool required premedical college science curricu-

lum, 2) incorporate known educational learning research for

structured, self-directed educational activities, and 3) to include

more individual competency based assessment tools to guaran-

tee that physicians are competent, ethical and professional (Irby

2010; Miller, 2010; Alpern, 2009; Leape, 2010; Fletcher, 2008).

Additionally, “all undergraduates should have access to educa-

tion in public health (IOM 2003). As noted by Cashman and

Seifer (2008) “Service-learning, a type of experiential learning,

is an effective and appropriate vehicle for teaching public

health and developing public health literacy”.

The commitment to these recommendations by the Univer-

sity of New Mexico Health Sciences Center School of Medi-

cine (UNM HSC SOM) is evidenced in the HSC vision “work-

ing with community partners, the UNM HSC will make more

progress in health and health equity than any other state by

2020” (Strategic Plan, 2010). The context of this vision is set

within the contraints of the following challenges. New Mexico

is geographically the fifth largest state in the United States,

ranks 36th in population size with two million residents, and is

one of four minority-majority states. It is a rural state with only

nine cities having populations over 30,000 and ranks 43rd in

per capita income (NM Quick Links, 2010; US Census Bureau,

2010). With regards to healthcare access, half of New Mexico’s

population lives in rural areas, yet two-thirds of its physicians

practice in urban areas. Thirty-two of its 33 counties are desig-

nated as Health Professional Shortage Areas as determined by

the Health Resources and Services Administration (HRSA,

2010) and NM ranks 16th highest in frontier counties.

In 2006, to support its mission and reflect the call to reform

medical education, UNM SOM implemented the Combined

BA/MD Degree program. This eight-year program results in

both a Bachelor of Arts and a Medical Degree. Its primary goal

is to improve the health and well-being of New Mexicans. It is

A. CLITHERO ET AL.

designed to help address the physician shortage in New Mexico

by selecting a diverse group of high school seniors who are

committed to practice in New Mexico’s communities of great-

est need (Cosgrove, 2007; Rabinowitz, 1999). The BA curricu-

lum is designed to prepare the students for entrance into the

UNM SOM program by emphasizing public health and equity

based perspectives.

Overview elements of the Bachelor of Arts/Medical Degree

(BA/MD) program at the University of New Mexico include:

(Combined BA/MD, 2010).

 Partnership between the Colleges of Arts & Sciences and

the School of Medicine.

 Undergraduate portion fully funded by the New Mexico

State Legislature including tuition, housing.

 BA/MD students pursue one of three degree options for

their undergraduate degree, all of which emphasize science

and liberal arts coursework.

○ Option 1: Arts and Sciences concentration;

○ Option 2: Health Medicine and Human Values concen-

tration;

○ Option 3: Biomedical Science concentration.

The curriculum is designed to provide a strong foundation

for practicing medicine with sensitivity to New Mexicans and

their public health and medical needs. Included in the custom-

ized curriculum are five integrated health seminars and partici-

pation in a summer community health project (Summer Practi-

cum) in a New Mexico rural or medically-underserved commu-

nity

Table 1 describes the five BA/MD Health Medicine and

Values Seminars and Summer Practicum which make up the

unique backbone of the BA curriculum. These classes prepare

the students to enter the MD curriculum with an enhanced ex-

posure to public health, ethics, health economics, cultural di-

versity awareness, literature, fine arts and medicine, and New

Mexico population health variables. These topics continue in

the MD curriculum culminating in all students receiving a pro-

fessional development Certificate in Public Health along with

their MD degree.

The Summer Practicum is an innovation in undergraduate

premedical preparation. The educational learning models that

support its development were Vygotsky’s historical sociocul-

tural approach, service learning, small group problem based

tutorials, self-reflective metacognitive narrative writing and

professional identity development through shadowing (John-

Steiner, 1996; Choon-Eng, 2009; Levine, 2008; Shapiro, 2006;

Table 1.

Health Medicine Human Values (HVMV) Seminars.

Contours of H ealth in New Mexico: Ethnic, economic, demographic,

and geographic variables impacting public health in New Mexico and

the Southwest.

Literature, Fine Arts, & Medicine; Links among health, illness,

literature and the arts, encompassing a diverse range of forms and

genres.

Health Economics, Politi cs, and Policy: Political and economic forces

that impact health care policies and practices.

Health and Cu ltural Di v ersity: Cultural variables that affect the

experience and practice of health and health care.

Ethics, Medic i ne, and Health: Ethical and legal considerations that

influence medical practices and decision-making.

Summe r P r acti c um: Introduction to the Core Functions and 10

Essential Services of Public Health.

Kitsis, 2011; Sheu, 2011).

While there are numerous medical school and other health

professional examples of community service learning and

community project requirements as part of the medical curricu-

lum, a PubMed search yielded no information on guided un-

dergraduate premedical community service opportunities. Be-

cause most international medical schools take students directly

from high school, aspects of this model may be of interest to

medical training outside the USA such as pre-practicum semi-

nars, on-site faculty guidance and reflection via narrative writ-

ing.

Through community engagement, the ultimate goal of the

Summer Practicum is for students to experience the connection

between social determinants of health and the health of com-

munity members, and how public health and medicine are in-

tertwined. Whether they recognize this as part of public health

or not, physicians diagnose, monitor health, mobilize commu-

nity partnerships, provide and evaluate care, and conduct re-

search and, by doing so, solidify the public health and medicine

relationship.

Curriculum

The Summer Practicum is a one month service-learning ex-

perience designed to enhance students’ knowledge and under-

standing of health issues and healthcare practice in rural and

underserved communities.

Given that there are numerous definitions of service-learning,

we adapted our definition from a variety of sources found on

the Community-Campus Partnerships for Health (CCPH) web-

site. CCPH is a nonprofit organization that “promotes health

equity and social justice through partnerships between commu-

nities and academic institutions.

http://depts.washington.edu/ ccph/index.html

The definition we adopted is:

Service learning has been defined as a type of experiential

education that involves people in both community service and

education. Service learning provides developmental opportuni-

ties that promote personal, social, and intellectual growth, as

well as civic responsibility and career exploration.” Specific

components that are emphasized in our program include:

1) Active integrated learning drawing lessons from the ex-

perience of performing service work and enhancing the knowl-

edge, values and skills of the participants

2) Engaging students and communities in as many aspects of

the project planning as possible

3) Meeting a real need in the community with age appropri-

ate, well organized outcomes oriented service

4) Collaboration involves all stakeholders in the planning,

execution and evaluation of the service

5) Reciprocity provides benefit to the recipient (BA/MD

communities) and the provider of the service (BA/MD students)

6) Reflection allows time for contemplation before (to pre-

pare), during (to troubleshoot) and after (to process and assess)

Students participate in the practicum during the second

summer of the BA portion of the BA/MD program. Figure 1

gives an overview of the preparatory sessions and Summer

Practicum. Prior to the practicum, students attend an 8-week

pre-practicum course that provides foundational information on

public health concepts, community assessment tools and com-

munity service basics. Students complete on-line Health Insur-

ance Portability and Accountability Act (HIPAA) training,

166

A. CLITHERO ET AL.

Figure 1.

Legend: Pre-practicum preparatory sessions and summer practicum curriculum overview.

Infection Control and Institutional Research Board (IRB) train-

ing. Both the students and physicians sign a student code of

conduct (see attachment). In addition, students receive training

in professionalism including how to introduce themselves to

patients and ask permission to remain in the room during an

exam or procedure. At the completion of the preparatory course,

students are divided into groups and sent to live for one month

in a rural New Mexico community, the Practicum.

The practicum has four components: 1) shadowing a local

community physician; 2) tutorials and homework assignments;

3) narrative writing; and 4) community project. By the end of

the practicum experience, it is expected that students will be

able to define a community; identify a community concern; dis-

cuss this issue of concern from both a clinical and a public

health perspective; identify possible solutions to the issue and;

suggest ways of monitoring the impact of solutions. Students

have assistance from community liaisons, local physicians, UNM

SOM faculty circuit riders, and UNM SOM faculty mentors.

Tutorials demonstrate the intertwining areas of public health

and medicine. Week 1 examines environmental factors (neigh-

borhood impact on health). Students investigate their commu-

nity by answering 25 questions by conducting a windshield

survey of both a “wealthy” neighborhood and an economically

disadvantaged neighborhood as identified by their community

coordinator. The goal is for the students to learn about the

physical composition of the community as well as the people

who live there and the services and facilities that are available.

The students are also asked to take photos that represent their

community as a whole. For example, if they had to describe

their community to someone who didn’t speak a common lan-

guage, what photos would capture the spirit of their community?

Week 2 focuses on structural factors (impact of wealth on

health). Students are asked to first think about their personal

beliefs regarding poverty, health and roles/responsibilities of

physicians. They then read three articles, “Poverty in America:

How Public Health Practice Can Make a Difference” (Erwin,

2008), “Poverty and Ill Health: Physicians Can, and Should,

Make a Difference” (McCally, 1998) and “The Nexus of Pov-

erty, Hunger and Homelessness in New Mexico” (Page-Reeves,

2013). The students then choose one of the community clinics

or hospital where they are shadowing and examine payment

and fees for a particular condition. Finally, they are asked to

find a list of items new parents should have (a layette) for a

newborn baby. They are given a list of products and they have

to “best guess” as to what the item costs. The students then go

out as a group to a local store and record the actual prices.

Week 3 emphasizes inequities and power gradients (impact of

education on health). After reading “Giving everyone the health

of the educated: an examination of whether social change

would save more lives than medical advances” (Woolfe, 2007)

and “the Robert Wood Johnson Foundation: Commission to

Build a Healthier America: Education matters for health”

A. CLITHERO ET AL.

(2009), students are asked to list and discuss some of the rea-

sons minority groups might have increased mortality rates; how

education might improve the health of individuals and the im-

pact of education on a particular condition. Week 4 is a culmi-

nation of the first three weeks by talking about policy and ad-

vocacy. Students are assigned readings including “Emergency

Medicine and Public Health: Stopping Emergencies before the

911 Call” (Kellerman, 2009) and “Imposing Personal Respon-

sibility for Health” (Steinbrook, 2006). Students look at exist-

ing prevention initiatives, legal remedies, public health initia-

tives and medical awareness campaigns while reflecting on

personal responsibility for health conditions.

Shadowing a local physician is an element of the Summer

Practicum curriculum, through which the student experiences

the rewards and challenges of being a rural healthcare practi-

tioner, and the advantages/disadvantages of the preceptor’s

specialty, practice model and location. They watch practitioners

interact with their patients and see a variety of medical prob-

lems and learn to link the patients’ medical problems with pub-

lic health concepts. This hands-on experience is supplemented

with weekly visits by a UNM faculty circuit rider who relates

readings and homework assignments to what students are ex-

periencing in the community. Community coordinators who

live and work in the assigned community also help guide the

student experience and give local perspectives.

The narrative writing element “promotes self-reflection and

increases self-awareness” (Shapiro, 2006). These megacogni-

tive skills may carry over into the medical school professional-

ism curriculum. Most people reflect, but the skill medical pro-

fessionals need, critical reflection, is different: According to

UCSF LeaP Learning from your Experiences as a Professional:

Guidelines for Critical Reflection (Aronson, 2012), Critical

Reflection is “the process of analyzing, questioning and re-

framing a personal experience to enhance learning and inform

future behavior.” It is a skill developed over time with practice

and feedback and is used by health professionals to promote

lifelong learning and improve outcomes.

Initially, students were allowed to write about anything they

chose. Some students did well with this, while others struggled

to identify an issue or used this as a timekeeping log. Currently,

topics are structured in order to further guide students and cre-

ate awareness. Topics include:

1) Describe a situation which was complex, surprising, un-

comfortable or uncertain using all five senses. Address your

own biases and/or prejudices by reframing the encounter from a

different point of view AFTER you have described it

2) What interests you about this community/practice? What

seems important?

3) What do you feel you are learning about medicine and

about yourself?

4) Other-student choice. For example:

a) Encounters with patients, colleagues, mentors;

b) Questions about the patients you are seeing;

c) Feelings about being in this particular community at this

particular time in this particular way;

d) What is easy, difficult, puzzling, enjoyable, confusing,

profound, boring, or rewarding about your experiences?

Students are required to write once per week to an assigned

UNM SOM faculty mentor. At the end of the practicum, stu-

dents choose one piece of their writing to read aloud in a forum

that includes their classmates, faculty, other interested person-

nel at the UNM HSC and community.

The community service project is a group project. Each

group of students addresses an important health issue identified

by the local community health council (Engaging Communities,

2010). As an example, in one community, the students re-

searched the prevalence of teen pregnancy and gathered opin-

ions through surveys of local community members. Students

present their findings to local key decision makers during the

final week and submit a written summary report. Upon return to

the University, students give oral and poster presentations to

the upcoming practicum students, faculty and invited commu-

nity members.

Methods

The Summer Practicum is evaluated by students completing

a course evaluation and a service learning course survey. The

first survey is an online course evaluation administered to stu-

dents at the conclusion of the summer practicum course. Stu-

dents are asked to assess course organization and objectives,

adequacy of time to complete assignments, course syllabus/

catalog, readings, the community project and the shadowing

experience with community physicians. Students rate each of

35 items on a 1 - 5 scale with 1 = strongly disagree and 5 =

strongly agree.

Completion of surveys at UNM is voluntary and all students

sign an informed consent document prior to participating in

survey research. The research described in this study was ap-

proved by the IRB at UNM.

Results

All sixty students from the first three classes who have com-

pleted the summer practicum course were included in this study;

21 students in each of the first two years and 18 students in the

most recent year, see Table 2. Fifty-two percent of the students

were female and 53% were under-represented minorities; al-

most two-thirds were from rural hometowns. All 60 students

completed a course evaluation and 55 of 60 (92%) completed

the service learning survey.

Students generally rated the summer practicum highly; the

mean overall scores for the 35 questions on the course evalua-

tion were 3.9, 3.9, and 4.2 for cohorts 2008, 2009, and 2010

respectively. Highest rated statements were those regarding the

shadowing experience as helping to understand their future role

as physician; learning about community health issues; learning

through the community project; and observing and learning

from a physician preceptor.

Discussion

In 2010, the UNM SOM ranked as one of the top 20 US

medical schools with a social mission index based on three

categories: “percentage of graduates who practice primary care,

work in a health professional shortage area and are underrepre-

sented minorities (Mullan, 2010).” The Summer Practicum

through the Combined BA/MD Program is a pre-medical edu-

cational model to enhance this social mission and support

medical education reform.

The Summer Practicum in our Combined BA/MD Program

occurs in the student’s undergraduate premedical academic

career (after four semesters of undergraduate work). It is de-

signed to provide students with an exposure to the practice of

medicine in rural NM, give them tools to evaluate health from a

168

A. CLITHERO ET AL.

Table 2.

Description of the 60 students participating in BA/MD Summer Practi-

cum program, 2008-2010 Update through 2012.

N (%)

Total 60 (100%)

Year of Summer Practicum

2008 21 (35%)

2009 21 (35%)

2010 18 (30%)

Gender

Female 31 (52%)

Male 29 (48%)

Minority status

Under-represented (Hispanic, Black, Native American) 32 (53%)

Not under-represented (Anglo, Asian) 28 (47%)

Hometown

Rural 38 (63%)

Urban 22 (37%)

community-based approach, and involve them in a public

health-based service learning project. It is critical that we pre-

pare students to practice in rural areas by allowing them to

experience the community first hand.

Overall, the results of the evaluation by the students were

very positive regarding content, design and implementation.

Highlights of the program for the students are reported as the

shadowing experiences, community activities and learning from

fellow students.

A unique aspect of this Summer Practicum is students’ par-

ticipation in community service learning during their under-

graduate premedical education. This service learning compo-

nent addresses: 1) reciprocal knowledge transfer between insti-

tutions and communities, and 2) involving community mem-

bers in identifying local health priorities (Hunt, 2011). Recipro-

cal knowledge transfer occurs as the students are in the com-

munity. The students benefit from shadowing local community

health care providers. They also learn from the community

about public health issues around which they design their local

community projects. The community receives the benefit of the

community project which the students design and conduct.

Additionally, many of these projects continue through the years

with the following year’s students continuing or augmenting

the project. Results are reported back to the community through

student presentations to appropriate organizations including

local school boards, rotary clubs, members of the New Mexico

Legislature, community health councils and hospital foundation

boards.

Enlisting active community members is paramount. Com-

munity members are engaged early in the educational process,

during the preparatory seminar series and continue to interact

with the students while they are in the community. The com-

munity members who serve as local coordinators are recruited

based on their reputations and roles in the health system of the

communities in which they live and work. Active coordinators

and the preceptors engage the students and make this course

interesting. The community residents welcome the students into

their homes, show them the recreational activities available and

go that extra step in working with the students. They give their

personal cell numbers in case of emergency, provide snacks

during tutorial, and arrange for optional outings for student

learning in the communities. The students remember these ef-

forts positively. This may help students choose subsequent

medical student rotations in that community. Students, who

expressed hesitation in going to remote areas, came back en-

thusiastic about their experience and “could see themselves

living in that community and practicing there”.

As academic programs develop, so do the curricula, staff and

faculty. In this situation, there have been changes to the faculty

instructing the seminar series which may affect the students’

responses. The seminar series has also been updated and ad-

justed annually, in part based on student feedback. Although

the core content is the same, the fine tuning may have affected

results. Another limitation is that the ultimate outcome of the

Summer Practicum is for graduates to practice in underserved

areas of NM. This outcome measure will not be assessable until

at least 2017, when the first cohort could e completing their

residencies and starting their medical career.

Future research for the Summer Practicum will include

qualitative assessment of the community projects and the im-

pact of the project in the local community. Also, we will con-

duct longitudinal studies of the students on future career

choices: location (rural versus urban), setting (e.g. group, pri-

vate, academic), and focus (e.g. primary care, community-based,

public health, etc.). An additional area for potential research

relates to whether this early experience in community service

and public health will influence these individuals to be involved

to a greater extent in community engagement later in their

medical careers. Outcome measures regarding this will not be

available for more than a decade.

In conclusion, the UNM SOM Combined BA/MD Program

was designed and implemented to address medical education

reform recommendations for preparing physicians for the 21st

century. In particular, the students entering the BA Summer

Practicum curriculum experience are embedded in an authentic

service learning environment that prepares them to address

public health and equity based issues. The Summer Practicum

curriculum also initiates them into a deliberate educational

ladder that continues into medical school and towards a com-

pletion of a Public Health Certificate and professional medical

identity.

Acknowledgements

The authors thank Dan Gonzales and Kim Halsten-Mora of

the Preceptorship Office, Karen McGillvray BA/MD Program

Manager and Margaret Dornedon BA/MD Office for their out-

standing coordination of all practicum logistics and tireless

dedication to the program. Special acknowledgement is given

to Dr. Lily Velarde for her originating ideas.

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