[The following notes were generated by Andrea Belovich, Ph.D.]

Building Pathways & Bridges on the Bumpy Road Towards Equity in STEM & Medicine

The Spring 2023 IAMSE Web Seminar Series, “Widening the Road to Health Professions Education: Expanding access for diverse and underserved populations,” began on March 2nd, 2023 and concludes on March 30th, 2023. In this five-part series, experts and innovators share their practices in recruiting and matriculating students from underserved populations into health sciences programs and creating pathways for students to meet the unique needs of their communities.

The opening seminar for this series, entitled “Building Pathways & Bridges on the Bumpy Road Towards Equity in STEM & Medicine” was co-presented as a panel discussion on March 2nd, 2023 by Drs. Jacqueline Ekeoba, Thomas Thesen, Mariam Manuel, and Lily Lam. Dr. Ekeoba is a Master Teacher in the Mathematics Department of the University of Houston’s College of Natural Sciences and Mathematics, and Dr. Manuel is a Clinical Assistant Professor and Science Master Teacher, also in the Mathematics Department of the University of Houston’s College of Natural Sciences and Mathematics. Dr. Thesen is an Associate Professor of Medical Education at the Geisel School of Medicine at Dartmouth, and Dr. Lam is a medical student advisor and an Assistant Clinical Professor in the Department of Medicine of the City University New York School of Medicine. Together, these speakers presented the challenges and obstacles faced by students from Underrepresented in Medicine (URiM) groups in the pursuit of careers in the fields of STEM and Medicine. These speakers also shared examples of their institutions’ solutions to promote equity, inclusion, and support for URiM students in STEM and medicine.

Dr. Ekeoba began the webinar with a brief introduction of the overall problem of the “leaky pipeline” that frequently occurs in STEM and medicine, which often results in students from URiM groups have low rates of entry into the STEM and medicine careers. Dr. Thesen then followed with data and statistics regarding the current state of underrepresented and diverse populations in medical practice and medical education. As seen in the 2021 National Healthcare Quality and Disparities Report from the Agency for Healthcare Research and Quality (US)1, there are significant disparities between the proportion of URiM groups in the general United States population compared to the proportion of URiM groups in the physician workforce.

Dr. Thesen then went on to explain the impacts these disparities have on inequity at both the individual and societal levels. Inequity at the individual level takes the form of reduced opportunities, including reduced access to higher paying professional jobs and limiting generational opportunities. On the societal level, these disparities lead to inequity in healthcare, as the lack of physicians sharing cultural and lived experiences similar to those of their patients can lead to the many well-documented, unequal outcomes along the lines of race and equity in medicine. Regarding the percentage of medical students who plan to serve in underserved areas, Dr. Thesen highlighted findings that show that medical students from URiM groups are more likely to return to underserved communities to practice medicine. Thus, graduating doctors from underserved groups is considered a strategy to expand patient access and improving quality of care in underserved communities.

Dr. Thesen next discussed challenges to expanding URiM representation in medicine, citing AAMC data2 showing that neither the application rate nor the acceptance rate for medical school from certain URiM groups have changed significantly since the 1970’s. Dr. Thesen also pointed out that once URiM students are accepted into medical school, they often find that relatively few medical school faculty are from URiM backgrounds2, so it can be a challenge for URiM students to find role models and mentors from their own communities or lived experiences provide career advice and opportunities and recommendations, making the medical school experience harder for URiM students. Dr. Thesen emphasized the importance of acknowledging the socioeconomic, educational, and psychosocial realities and barriers that many URiM students face. Thus, these challenges and other systematic barriers need to be considered when creating pipeline programs with the goal of reducing “leak” to support URiM students on their path to STEM and Medicine careers.

Next, Dr. Manuel presented an example of a successful pathway (pipeline) program that begins at the high school level: the NSF-funded STEM Research Inquiry Summer Enrichment (STEM-RISE) program at the University of Houston. The STEM-RISE program is an interdepartmental collaboration between the College of Natural Sciences and Mathematics and the Tilman J. Fertitta Family College of Medicine at the University of Houston, along with the Jack Yates High School, which is a high-needs public high school in the historic neighborhood of Third Ward in Houston. Dr. Manuel described this program as an authentic community-based partnership program, as they worked together with the local community to plan the project. Dr. Manuel emphasized the importance of having strong interpersonal connections between members of the different schools, as this helps form a stronger community with other teachers and supports with recruitment efforts.

In short, the STEM-RISE experience is a 6-week summer program that includes 3 participant groups: medical students, undergraduate STEM majors in the teachHouston program, and high school students. All participants are offered incentives, which includes a summer professional development program and a stipend for medical and undergraduate students. The high school students also receive a stipend and gain hands-on STEM and laboratory experiences, which includes lessons on scientific principles and topics to support their laboratory learning outside of the lab. In combination with the opportunity to interview campus STEM faculty, these students are supported in the college and career readiness by being allowed to tour the campus and interact with a variety of campus resources. The program concludes with a celebratory research symposium and a group bowling party.

Dr. Ekeoba then shared more information about the layered mentoring that occurs throughout the STEM-RISE program and the research symposium. High school students are paired together and are assigned to different laboratory projects, but they are also grouped with undergraduate, graduate and medical school students to provide peer and near-peer mentorship along the education and career continuum. Undergraduate students also participate in a “Research Methods” course that allows them to conduct their own research and learn lessons they can carry forward into their own teaching careers. Faculty are also part of this layered mentorship, providing formalized mentorship time to help teach students how to be future mentors and teachers themselves. In addition to formal experiences, informal conversations at mealtimes provide opportunities for development of students’ college applications and career path planning. Dr. Ekeoba concluded this segment of the webinar with a video testimonial from a medical student STEM-RISE participant, who shared her story as a first-generation URiM medical student and how much she valued being part of supporting younger high school and undergraduate students as a mentor.

Dr. Manuel then described more of the inclusive community created by the STEM-RISE program, which culminates in the end-of-program Research Symposium, which focuses on the accomplishments of the STEM-RISE participants. In addition to presenting their research projects, high school student participants are also asked to give a presentation of the career pathway they would like to pursue. Dr. Manuel stated that the supportive environment of the symposium provides positive feedback and encouragement for URiM high school students to pursue careers in STEM and Medicine.

Dr. Lam then continued the webinar with more information about the Health Professions Mentorship Program (HPMP) at the Sophie Davis Biomedical Education Program CUNY School of Medicine, with is an 18-month pipeline/pathway program designed for rising high school juniors and seniors. Similar to the STEM-RISE program a the University of Houston, CUNY’s HPMP involves layered and multi-tiered mentoring. Students are placed into small groups and are assigned to a medical student mentor. High school students in the second year of the program are also encouraged to provide mentorship to junior students, which also helps students develop leadership and mentorship skills. Monthly mentorship sessions occur throughout the duration of the program, with faculty oversight and additional educational support from teaching assistants. During these monthly sessions, students work on developing effective study skills, professionalism and time management skills.

During the first summer of the program, students participate in learning sessions that focus on population health, health care disparities, and social determinants of health to help participants develop a deeper understanding of the complex social and environmental factors that impact health outcomes. Most participants apply their knowledge and skills to community-based projects to propose solutions to health care challenges and have opportunities to present a poster of their project. During the second summer, students are exposed to a variety of health themes and problems as well as health care careers ranging from medicine to nursing to dentistry and engineering. Mentors and teaching assistants give lectures based on what they have learned during medical school, including lectures on organs systems and the basics of obtaining a patient history and conducting a physical exam. The program culminates in a final poster presentation of a research project, followed by continued mentorship on navigated college applications and readiness.

After discussing funding sources for the program and the support available to participants, Dr. Lam presented program outcomes, including testimonials from HPMP graduates. The program began in 2015, with the first class graduating in 2017. Of the students who complete the HPMP, roughly 50% pursued a major in a health care-related field, with 10-20% of each graduating class enrolling in CUNY’s combined 7-year BS/MD program.

Drs. Thesen and Manuel concluded the webinar by providing tips and sharing lessons learned for audience members considering developing pathway programs at their own institutions. Possible avenues for funding include the NSF, the NIH, private foundations, school district funding programs, alumni associations, etc., although audience members may wish to explore funding mechanisms that target specific populations. The importance of creating a welcoming environment for URiM students is vital, as programs should aim to bring students into a nurturing environment where they experience belongingness. This is also important to consider when choosing participating laboratories, mentors, and leadership teams, so that the program’s pedagogy and philosophy is properly embodied as a focus on strength and opportunity rather than a deficit mindset. Direct recruiting at high schools is also sometimes necessary to prevent gatekeeping and to encourage students personally to participate. Near-peer mentorship is also a key factor to building a supportive community, as well as team building exercises and icebreakers that involved all participants as well as community members.

References

1. 2021 National Healthcare Quality and Disparities Report. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Dec. Report No.: 21(22)-0054-EF
2. Association of American Medical Colleges. AAMC.org

[The following notes were generated by Tracey A.H. Taylor, Ph.D. and Andrea Belovich, Ph.D.]

Lessons Learned in Developing Accelerated 3-Year MD Programs

In the second session of the series, three experts from the Consortium of Accelerated Medical Pathway Programs (CAMPP) spoke of “Lessons Learned in Developing Accelerated 3-Year MD Programs”. Dr. Joan Cangiarella, M.D. of the NYU Grossman School of Medicine began the session by defining an accelerated medical pathway program as a program that confers the MD degree in less than four years. She said that three-year programs are common in Canadian medical schools and that the first modern program in the United States started in 2010 at Texas Tech University. Interest in these programs is growing, as the group published survey data in 2016 and found that 35% of medical schools (n=127) said they were considering the development of an accelerated pathway program (Cangiarella et al. Med Educ Online, 2016). The general structures of these programs contain a standard MS1 and MS2 year that includes a summer of education in order to meet the LCME (Liaison Committee on Medical Education) accreditation 130-week requirement. The MS3 and MS4 years are usually condensed. Most programs have a directed pathway to an affiliated residency program, but this is not a requirement.

The biggest mission of 3-year accelerated programs is debt reduction where students save a year of tuition and enter the work force one year earlier, to save an estimated $250,000.00. Missions of other programs include serving underserved communities, or focusing on primary care and family medicine. Dr. Cangiarella also described the programs in the CAMPP, which was initiated from a Josiah Macy Jr. Foundation grant in 2014, and include the original seven programs from 2015 (NYU, UC-Davis, Penn State, University of Louisville, MCW-Green Bay Central, Mercer, and McMaster). There has been continued growth every year with new programs joining each year since 2015. One of the core goals of the formation of this group was to identify and disseminate best-practices in the formation of an accelerated pathway program in medical education, addressing diversity, logistical, regulatory, professional development, and competency concerns.

Following this introduction to 3-year accelerated programs, Dr. Cagiarella spoke more specifically about the NYU Grossman accelerated 3-year MD (3YMD) pathway. Developed as part of a major curriculum revision in 2010 that included numerous pathways. The goals were to provide individualized choice, reduce debt, and improve the UME-GME continuum. The medical school is now tuition-free and this was the first step on that path. NYU Grossman was the first medical school in the US to offer a 3YMD pathway to a select group of students with a directed pathway to one of 21 NYU-Langone Medical Center residency programs at the time of admission. This program is highly competitive and was offered as part of the regular admissions process. Students needed to know which specialty they wanted to pursue upon admission, and still participate in the NRMP to be accepted into the residency program following UME graduation after 3 years. The school currently has 40 residency spots available to this program, and the number of slots per specialty is known upon admission. There are various portals of entry to the program: pre-matriculation, during the 4-year MD program (end of year 1 or end of year 2), or through the MD-PhD program. Currently, the 3YMD program is 18 weeks shorter than the traditional four-year pathway at NYU Grossman, and contains a mentoring portion. Between 2013 and 2022, there have been 198 students accepted into the program, representing all residencies available. Of those, 138 have graduated and 43 are current students. A further seventeen students decelerated (either chosen or counseled to do so) and 12 switched specialties. The students overall perform very similarly to their four-year peers with the only differences being performance on step 1 and step 2 (J Graduate Medical Education, February 2022). The program has been so successful that the school has undergone a recent curriculum redesign to expand the 3YMD pathway.

Dr. Catherine Coe, M.D. of the University of North Carolina at Chapel Hill next discussed the FIRST (fully integrated readiness for service training) program. She started by stating “if you’ve seen one 3-year pathway program, you’ve seen one-3-year pathway program”, and then went on to describe the program at the University of North Carolina. A goal of the program was to increase the physician workforce in the state by reducing barriers and educating students at both the UME and GME level, through an accelerated and enhanced 3-year medical school curriculum. Following 3 year of medical school and residency, graduating physicians complete 3 years of service in a rural and/or underserved area within the state of North Carolina. The program began in 2018 and now offers residency options in Family Medicine, General Surgery, Pediatrics, and Psychiatry at all four of the regional sites. The program reduces barriers and harmonizes the transitions from UME to GME to medical practice. The curriculum consists of an 18-month foundation phase curriculum, followed by a 12-month clinical phase, and 12-16 months of individualization or elective time. Students spend one half day per week in the clinic of their chosen specialty starting at the first week of medical school. Summer between the first and second year contains 8-weeks of the clinical phase. In terms of outcomes to date, there have been 37 students matriculate with 19 total graduates. Six students chose to decelerate and three students changed specialties. All graduates perform similarly to graduates of the 4-year program in nearly all metrics, with the exception of slightly lower step 1 scores.

Dr. Gladys Ayala, M.D., Dean of the NYU Long Island School of Medicine next spoke of the exclusively 3-year medical school program at her institution. This program was developed following the success of the 3-year program described by Dr. Cagiarella. The primary aim is to
train physician leaders who are committed to practice in specific primary care disciplines and address the physician work-force shortages in internal medicine, pediatrics, obstetrics & gynecology, and general surgery. Like the other programs described, the three-year accelerated curriculum is followed by a pre-chosen residency program, thereby reducing barriers in the UME to GME transition. The curriculum uses problem-based learning as the core teaching modality, and offers tuition-free scholarships to all students, and a debt-free scholarship to those with the greatest need. The program includes a robust coaching (academic and professional development), diversity mentoring, and specialty advising system. The programs is committed and focused on diversity, equity, and inclusion with a student-run clinic, a pipeline program, and service learning projects. The class-size is small with 24 students and a future maximum size of 40 students. In terms of outcomes, 20 students have graduated (one class) with 90% of students staying in primary care specialties.

Lastly, Dr. Coe summarized the discussion by listing benefits of accelerated 3-year MD pathways as including accelerated and individualized entry to desired specialty, being valuable to those with advanced degrees and career interests, including reduced debt and earlier career earnings, facilitated continuum of training from UME through GME, and including intensive mentorship that begins in the first year. The CAMPP has published a roadmap for creating an accelerated 3-year program (Med Educ Online 2017). Dr. Coe described the consortium and the many benefits of CAMPP, including some of the manuscripts that have been published from the group (Cangiarella et al. 2017 Acad Med; Leong et al. 2017 Med Educ Online; Modrek et al. 2021, Acad Med; Cangiarella et al. 2020 Acad Med), and positive outcomes from these programs in terms of preparedness, student satisfaction, wellness, and reduced debt. These programs provide individualized curricula with close mentorship and support. The webinar closed by sharing an invitation to join CAMPP as a way to collaborate, network, and share best practices (www.acceleratedmdpathways.org).

References
• Cangiarella J, Gillespie C, O’Shea J, Morrison G, Abramson SB. Accelerating medical education: a survey of deans and program directors. Med Educ Online 2016;21:31794.
• Cangiarella J, K Eliasz, A Kalet, E Cohen, S Abramson, C Gillespie. A Preliminary Evaluation of Students’ Learning and Performance Outcomes in an Accelerated 3-Year MD Pathway Program. J Grad Med Educ 1 February 2022; 14 (1): 99–107. doi: https://doi.org/10.4300/JGME-D-21-00284.1
• Leong SL, J Cangiarella, T Fancher, L Dodson, C Grochowski, V Harnik, C Hustedde, B Jones, C Kelly, A Macerollo, AC Reboli, M Rosenfeld, K Rundell, T Thompson, R Whyte & M Pusic (2017) Roadmap for creating an accelerated three-year medical education program, Medical Education Online, 22:1, DOI: 10.1080/10872981.2017.1396172
• Cangiarella, J; Fancher, T; Jones, B; Dodson, L; Leong, SL; Hunsaker, M; Pallay, R; Whyte, R; Holthouser, A; Abramson, SB. Three-Year MD Programs: Perspectives From the Consortium of Accelerated Medical Pathway Programs (CAMPP). Academic Medicine 92(4):p 483-490, April 2017. | DOI: 10.1097/ACM.0000000000001465
• Cangiarella, J; Cohen, E; Rivera, R; Gillespie, C; Abramson, S. Evolution of an Accelerated 3-Year Pathway to the MD Degree: The Experience of New York University Grossman School of Medicine. Academic Medicine 95(4):p 534-539, April 2020. | DOI: 10.1097/ACM.0000000000003013
• Modrek, AS; Tanese, N; Placantonakis, DG; Sulman, EP; Rivera, R; Du, KL; Gerber, NK; David, G; Chesler, M; Philips, MR; Cangiarella, J. Breaking Tradition to Bridge Bench and Bedside: Accelerating the MD-PhD-Residency Pathway. Academic Medicine 96(4):p 518-521, April 2021. | DOI: 10.1097/ACM.0000000000003920