Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program

(2021) 21:589 Catalanotti et al. BMC Medical Education https://doi.org/10.1186/s12909-021-03006-x Open Access RESEARCH ARTICLE Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program Jillian S. Catalanotti1* , David K. Popiel2 and April Barbour1 Abstract Background: Accessing subspecialty care is hard for underserved patients in the U.S. Published curricula in underserved medicine for Internal Medicine residents target future-primary care physicians, with unknown impact on future medicine subspecialists. Methods: The aim was to retain interest in caring for underserved patients among Internal Medicine residents who plan for subspecialist careers at an urban university hospital. The two-year Underserved Medicine and Public Health (UMPH) program features community-based clinics, evening seminars, reflection assignments and practicum projects for 3–7 Internal Medicine residents per year. All may apply regardless of anticipated career plans after residency. Seven years of graduates were surveyed. Data were analyzed using descriptive statistics. Results: According to respondents, UMPH provided a meaningful forum to discuss important issues in underserved medicine, fostered interest in treating underserved populations and provided a sense of belonging to a community of providers committed to underserved medicine. After residency, 48% of UMPH graduates pursued subspecialty training and 34% practiced hospitalist medicine. 65% of respondents disagreed that “UMPH made me more likely to practice primary care” and 59% agreed “UMPH should target residents pursuing subpecialty careers.” Conclusions: A curriculum in underserved medicine can retain interest in caring for underserved patients among future-medicine subspecialists. Lessons learned include [1] building relationships with local community health centers and community-practicing physicians was important for success and [2] thoughtful scheduling promoted high resident attendance at program events and avoided detracting from other activities required during residency for subspecialist career paths. We hope Internal Medicine residency programs consider training in underserved medicine for all trainees. Future work should investigate sustainability, whether training results in improved subspecialty access, and whether subspecialists face unique barriers caring for underserved patients. Future curricula should include advocacy skills to target systemic barriers. Keywords: Underserved medicine, Community health, Graduate medical education *Correspondence: 1 Department of Medicine, The George Washington University, Washington, DC, USA Full list of author information is available at the end of the article Background Health disparities have numerous causes, among them disparate access to primary care and to timely subspecialty care. In 2018, the U.S.’s 7015 Health Professional Shortage Areas (HPSAs) were home to over 78 million © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Catalanotti et al. BMC Medical Education (2021) 21:589 people [1]. In the U.S., medical care must be purchased, most commonly by a health insurance plan and/or an individual. Physicians are not legally required to provide non-emergency care, nor to accept any particular health insurance plan. Low reimbursement rates compared to other insurance plans are the leading reason physicians do not accept Medicaid, the government-funded health insurance plan for qualified poor Americans [2]. According to a 2015 survey of outpatient physicians across multiple fields, 71% accepted Medicaid, 85% accepted Medicare and 90% accepted private insurance [3]. The Affordable Care Act expanded the number of patients who qualified for Medicaid, markedly decreasing the number of uninsured patients, but made no provisions to address the resultant increased demand for subspecialty care [4]. The Association of American Medical Colleges projects a potential national shortage of up to 49,300 primary care physicians (PCPs) and up to 9600 medicine subspecialty physicians by 2030 [5]. Demographic trends in the U.S. suggest that the overall demand for physicians is likely to grow proportionally faster for minority populations [6]. Federally Qualified Health Centers (FQHCs) provide primary care medical services to patients from underserved populations. In exchange for funding from the federal government, FQHCs must see all patients regardless of ability to pay or health insurance status. In a 2004 survey of medical directors of FQHCs by Cook, et al., respondents reported that 25% of visits resulted in referrals to medical services not provided at the center [7]. These subspecialty services were harder to obtain for patients with Medicaid and markedly more challenging for uninsured patients [7]. The most frequently reported barriers to access were providers not accepting patients’ insurance, requiring payment up front, and insurance not covering the services requested. Two of these three barriers are provider- or practice-dependent. In a 2001 survey of medical directors of community health centers (CHCs), 35% of respondents said they or their physicians attempt to negotiate with off-site subspecialists on behalf of uninsured patients to obtain lower rates, and 20% reported that physicians rely upon professional networks and friends to provide subspecialty care to uninsured patients, a practice informally known as “tin cup medicine.” [6, 8] Data from the Community Tracking Study Physician Survey showed that from 1996 to 2005, both the number of physicians providing charity care (i.e., care for which no pay is sought), and the number seeing Medicaid patients decreased [9]. Medical directors of FQHCs affiliated with a medical school or hospital reported less difficulty accessing subspecialty care [7], however in a 2003 survey of faculty at 121 academic health centers, Page 2 of 8 (...truncated)